Caitlin Mazurek
9/6/2011
KNH 411
Case 6: Hypertension and Cardiovascular Disease
1. Define blood pressure.
Blood pressure consists of both the contraction, or systole, and the relaxation, or
diastole, of the heart muscle. The force put out by the blood onto the blood vessels is the
actual blood pressure. Pg. 286
2. How is blood pressure normally regulated in the body?
Blood pressure is normally regulated in the body by the heart and the strength of
ventricular contraction, end diastolic volume or EDV, and mean aortic blood pressure or
MAP. All these are determined by the venoconstriction as well as respirations. The
increase in respiration allows for better blood flow to the heart and therefore allows for
a better blood pressure. Pg. 286
3. What causes essential hypertension?
The direct causes of primary or essential hypertension is unknown but may be related
to lifestyle factors. These would include diet, no exercise, stress, smoking, and obesity.
4. What are the symptoms of hypertension?
The biggest symptom of hypertension is chronic elevated blood pressure. Only one of
the two numbers must be elevated in order for it to be considered hypertension. Vision
problems may occur, but there are relatively no visible symptoms of hypertension. This
is why it is known as the “silent killer.” Pg. 288
5. How is hypertension diagnosed?
Hypertension is diagnosed by reading the blood pressure. If either the systolic or
diastolic pressure is at or above 140/90 mmHg, it is considered to be hypertensive.
Only one number must be at or above this in order for it to be hypertensive. Pg. 288
6. List the risk factors for developing hypertension.
Risk factors for developing hypertension include genetic heart problems or HTN,
smoking, overweight, as well as poor lifestyle choices in diet. Hypertension can
eventually cause congestive heart failure, kidney failure, myocardial infarction, stroke,
and aneurysms if it is left untreated. Vision problems can also occur if blood vessels
burst or bleed within the eyes. It can also lead to decreased left ventricular ejection
fraction, ventricular arrhythmias, and sudden cardiac death. This is a serious problem
and hypertension should be taken care of as soon as it is started.
7. What risk factors does Mrs. Anderson currently have?
Mrs. Anderson currently has the risk factors that include the genetic component where
the patient’s mother had high blood pressure, heart problems and all this led to a heart
attack. Mrs. Anderson has had high blood pressure where it was 160/100 mmHg. She is
also overweight still a smoker of one pack of cigarettes a day.
8. Hypertension is classified in stages based on the risk of developing CVD. Complete the
following table of hypertension classifications.
Category
Normal
Prehypertension
Hypertension Stage 1
Hypertension Stage 2
Blood Pressure mm Hg
Systolic BP
< 120
And
120-139
Or
140-159
Or
> 160
Or
Diastolic BP
< 80
80-89
90-99
> 100
9. Given these criteria, which category would Mrs. Anderson’s admitting blood pressure
reading place her in?
Hypertension Stage 2 due to her 160/100 mmHg blood pressure reading.
10. How is hypertension treated?
Hypertension is treated primarily through weight loss and lifestyle changes. An exercise
regimen should be started to increase physical activity and hopefully help with weight
loss. A change in diet can be made to try and reduce sodium intake as well as decrease
the amount of fat eaten and increase the number of fruits, vegetables, lean proteins, and
healthy carbohydrates. Medication can also be prescribed if needed to help with the
initial control of blood pressure. Mrs. Anderson is currently on a walking schedule in
attempt to increase physical activity as well as pharmacologic therapy with thiazide
diuretics and reinforcement of lifestyle modifications to decrease fat intake.
11. Dr. Thornton indicated in his admitting note that he will “rule out metabolic syndrome.”
What is metabolic syndrome?
Metabolic syndrome is a combination of conditions such as elevated blood pressure,
increase in insulin levels, excess body fat around the waist, and abnormal cholesterol
levels. The more factors there are, the higher chance of heart disease, stroke and
diabetes.
12. What factors found in the medical and social history are pertinent for determining Mrs.
Anderson’s CHD risk category?
Mrs. Anderson smokes cigarettes and has been around cigarette smoke for thirty years,
she has Stage 2 hypertension now for two years, increased LDL cholesterol of 210,
increased LDL/HDL ratio of 7.0, and family history of premature coronary heart disease
with her mother.
13. What progression of her disease might Mrs. Anderson experience?
Mrs. Anderson is already at Stage 2 Hypertension. If this does not get controlled soon,
then there is a chance of heart problems leading to CAD, or CVD. This could also lead to
vision problems with the chance that a blood vessel is blown causing blurry vision.
14. What are the most recent recommendations for nutrition therapy in hypertension?
Explain the history of and rationale for the DASH diet.
Some of the most recent recommendations for nutrition therapy in hypertension
include the DASH diet and the PREMIER trials have helped. These diets include
decreasing sodium, saturated fat, and alcohol and increasing calcium, potassium, and
fiber in order to lower blood pressure. The DASH diet stands for Dietary Approaches to
Stop Hypertension. It made its first breakthrough in the late 1990s and they focused on
reducing sodium intake and increasing potassium, magnesium, calcium, and fiber. The
limitation of sodium for a 2000 kcal diet is 2400 mg of sodium.
15. What is the rationale for sodium restriction in treatment of hypertension? Is this
controversial? Why or why not?
The rationale for sodium restriction in treatment of hypertension is that urinary
sodium excretion has a significant and direct relationship with systolic blood pressure.
The use of sodium restriction has been controversial, but there is still evidence that a
reduction in sodium will help with the controlling of blood pressure. Studies show that
sodium modifications may reduce incidence of hypertension by as much as 17%. It is
controversial in the sense that it does not help everyone. Only about 5% of people are
salt sensitive, leading some people to believe that it is a waste to try and restrict sodium
in the diet. Pg. 294
16. What are the Therapeutic Lifestyle Changes? Outline the major components of the
nutrition therapy interventions.
Therapeutic Lifestyle Changes come from the National Cholesterol Education Program
and these recommendations incorporate nutrition therapy as a major component of
treatment for cardiac disease, hyperlipidemia, and hypertension. It is important to
encourage weight loss and eventually decrease the required dosage of medications. A
diet rich in fruits and vegetables as well as foods with reduced saturated and total fat
will also benefit this diet. Pg. 211
17. The most recent recommendations suggest the therapeutic use of stanol esters. What
are they, and what is the rationale for their use?
The TLC diet recommends 3-4 g/day of stanol esters. Stanol esters are bioactive
substances added to a food product or taken as a supplement and are taken for the
reduction of lipid levels. Pg. A-6
18. Calculate Mrs. Anderson’s body mass index (BMI).
25.8 BMI
19. What are the health implications of this number?
Mrs. Anderson is considered overweight. Being overweight leads to heart disease and
high blood pressure. Pg. 239
20. Calculate Mrs. Anderson’s resting and total energy needs. Identify the
formula/calculation method you used and explain your rationale for using it.
Mrs. Anderson’s resting energy expenditure is 1346 kcal/day when calculating using
the Mifflin-St. Jeor method. This method was used because it is the most accurate based
off of recent studies. Mrs. Anderson’s Estimated Energy Requirement was calculated
using the following equation: 662 - 9.53 x age + PAL x (15.91 x wt + 539.6 x ht) Her age
is 54 years old, and her weight in kilograms is 72.7 and her height in meters is 1.68. The
physical activity level that was used was 1.11 due to her not very active lifestyle and
only 4-5 day walking plan if she does it at all. After using this equation and these
numbers, her EER came out to 2416 calories.
21. How many calories per day would recommend for Mrs. Anderson?
Since Mrs. Anderson is looking to lose a little weight, I would recommend a 2000 calorie
diet. This will allow her to get the energy she needs from the calories as well as manage
her weight to get her hypertension under control and limit her risk factors for the
future.
22. Determine the appropriate percentages of total kilocalories from carbohydrate, protein,
and lipid.
For a 2000 calorie weight loss and hypertension diet, it is important to decrease lipid
consumption and increase lean protein and maintain carbohydrate consumption.
Carbohydrate 60%: 2000 x .6 = 1200 kcal/day or 300 g/day
Protein 20%: 2000 x .2 = 400 kcal/day or 100 g/day
Lipid 20%: 2000 x .2 = 400 kcal/day or 44 g/day
23. Using a computer dietary analysis program or food composition table, compare Mrs.
Anderson’s “usual” dietary intake to her prescribed diet (DASH/TLC diet).
Mrs. Anderson’s usual diet contains 44% carbohydrates, 38% fat, and 14% protein with
a small percentage towards alcohol. Since Mrs. Anderson does not drink often, this is
not something to take too seriously. What needs to change from her current diet, is the
amount of fat that is eaten daily. Of the fat eaten daily, 11% is saturated fat. Her total
calories for her 24-hour recall were approximately 3,000 calories. Her usual diet is far
off from where her prescribed diet should be. She needs to make healthier options and
consider not adding the salt and pepper to her potato, chicken, and glazed carrots. The
following shows how much her diet requires and then how much she actually ate:
Carbohydrates: 300 g/day – 336.9 g/day
Protein: 100 g/day – 106.6 g/day
Lipids: 44 g/day – 130.3 g/day
The amount of lipids eaten drastically increases weight and therefore does not help
hypertension or any other problems with the body. The carbohydrates eaten
throughout the day could have been better if whole grains were used and the starchy
potato could have been taken out. The carrots could have just been steamed and not
glazed or served with only pepper.
Below is a chart showing each of the food items from the 24-hour recall and their
nutrition value for each item.
Food Item
Oatmeal with
Potassium
Sodium
Magnesium
Calcium
Total
Saturated
Cholesterol
Fiber
(minimum
(maximum
(500 mg)
(minimum
Fat
Fat (g)
(mg)
(g)
4,700 mg/
2,400 mg/
1,240 mg)
(g)
120 mEq)
100 mEq)
184.8 mg
286.3 mg
59.6 mg
163.6 mg
2.8 g
0.5 g
0
4.3 g
252.5 mg
11.4 mg
17.5 mg
12.1 mg
.086
.01 g
0
0
2.7 g
14.4 mg
0.67
margarine and
sugar
Coffee
g
Glazed donut
45.9 mg
180.9 mg
7.7 mg
27.0 mg
10.3
g
Tomato Bisque
1467.7
2691.8
60.9 mg
450.7 mg
soup
mg
mg
Saltine crackers
46.2 mg
321.6 mg
0.2 mg
20.4 mg
Baked Chicken
413.4 mg
668.9 mg
45.6 mg
24.0 mg
16.0
g
7.6 g
54.8 mg
1.2 g
3.4 g
0.5 g
0
0.9 g
13.1
3.7 g
141.7 mg
0
0.4 g
0
2.3 g
12.2 mg
1.13
g
g
Baked Potato
610 mg
376 mg
39.0 mg
7.8 mg
0.16
g
Salad
272.4 mg
466.3 mg
0.4 mg
57.1 mg
23.58 3.63 g
g
Butter Pecan
0
446.1 mg
0
353.6 mg
Ice Cream
28.0
g
11.4 g
49.0 mg
2.4 g
0
0
0
g
Regular Beer
118.0 mg
10.7 mg
25.0 mg
14.3 mg
0
24. What nutrients in Mrs. Anderson’s diet are of major concern to you?
Potassium, vitamin C, vitamin D, and vitamin E are all concerning as well as sodium. The
first four nutrients should all be increased while sodium intake needs to be decreased.
Water should also start being added into the diet more to aid in satiety and help in
viscosity of the blood.
25. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic term.
Obesity, hyperlipidemia, coronary artery disease, and low potassium intake
26. Dr. Thornton ordered the following labs: fasting glucose, cholesterol, triglycerides,
creatinine, and uric acid. He also ordered an EKG. In the following table, outline the
indication for these tests (tests provide information related to a disease or condition).
Parameter
Glucose
Normal Value
70-110 mg/dL
Patient’s
Reason for
Value
Abnormality
92
Diabetes
Nutrition Implication
If high blood glucose,
then the body could be
insulin resistant or not
producing enough
insulin causing
diabetes, high
carbohydrate intake
can lead to high
glucose levels
BUN
8-18 mg/dL
20
High Blood
High levels of BUN can
Urea Nitrogen
lead to poor kidney
function. High levels
can result from high
concentration protein
breakdown.
Creatinine
0.6-1.2 mg/dL
0.9
Kidney failure
If the kidneys were not
working properly, then
the creatinine would
not be taken out of the
blood properly,
causing excess
creatinine in the blood
Total
120-199 mg/dL
270
cholesterol
High
If the total cholesterol
cholesterol
levels are above 199,
then there is a very
high chance of getting
cardiovascular disease
or having other heart
problems.
HDL-cholesterol
> 55 (women)
30
Low HDL or
Low HDL is
mg/dL
hypoalphalipo-
problematic, because
> 45 (men) mg/dL
proteinemia
then the there is an
acceleration of the
development of
atherosclerosis
LDL-cholesterol
< 130 mg/dL
210
High LDL or
LDL is the bad
cholesterol and will
adhere to artery walls
and in tissues causing
blood flow to be
blocked
Apo A
Apo B
101-199 (women)
75
Low Apo A
This can lead to
mg/dL
cardiovascular disease
94-178 (men)
and build up of plasma
mg/dL
concentration
60-126 (women)
140
High Apo B
This can lead to higher
mg/dL
LDL levels and
63-133 (men)
therefore increasing
mg/dL
chances of CAD, CVD,
and high blood
pressure
Triglycerides
35-135 (women)
40-160 (men)
150
High
This can raise your risk
Triglycerides
for heart disease and is
a sign of metabolic
syndrome
27. Interpret Mrs. Anderson’s risk of CAD based on her lipid profile.
The risk factors for CAD in general are family history, age, sex, obesity, dyslipidemia,
hypertension, diabetes, physical inactivity, and cigarette smoking. Based on Mrs.
Anderson’s lipid profile it is evident that her total cholesterol levels are quite high and
she has twice the risk of heart disease compared to someone whose cholesterol is
below 200 mg/dL. Her HDL cholesterol levels are 30 where anything less than 40
mg/dL is a major risk factor for heart disease. Her LDL cholesterol levels are at 210, and
anything above 190 mg/dL is considered to be very high. Lastly, her triglyceride levels
are at 150 and this is considered to be borderline high. Looking at her lipid profile, it is
clear that Mrs. Anderson is at a high risk of coronary artery disease. All of her levels
need to be changed in order to better manage everything.
28. What is the significance of apolipoprotein A and apolipoprotein B in determining a
person’s risk of CAD?
Apolipoprotein is the protein portion of the lipoprotein and this provides structural
integrity and allows for receptors to recognize the lipoprotein particle. It also effects the
density of the structure and allows for the classification. Apolipoprotein A is the major
protein component of HDL and apolipoprotein B is the major protein component in
LDL. Realizing that Mrs. Anderson’s Apo A is low and her Apo B is high is an indication
that she is a high risk individual for coronary artery disease.
29. Indicate the pharmacological differences among the antihypertensive agents listed
below.
Medications
Mechanism of Action
Nutritional Implications
Diuretics
Decrease blood volume
Increase in potassium
by increasing urinary
supplements, dry mouth pg
output, inhibit renal
291
sodium and water
reabsorption
Beta-blockers
Blocks B-receptors in
These lead to nausea,
heart to decrease heart
diarrhea, calcium may
rate and cardiac output
interfere with absorption,
upset stomach, dry mouth,
stomach pain, gas or
bloating, and heartburn
Calcium-channel blockers
Affect the movement in
Leads to edema, nausea,
calcium, cause blood
heartburn, heart failure or
vessels to relax, therefore greater than first degree
reduce vasoconstriction
heart block, avoid natural
licorice, limit caffeine, and
avoid or limit alcohol
ACE inhibitors
Vasodilators that reduce
Hypotension especially in
BP by decreasing
elderly patients, can worsen
peripheral vascular
renal function,
resistance by interfering
hyperkalemia, dysgeusia,
with the production of
causes dry, nonproductive
angiotensin II from
cough, and salt substitutions
angiotensin I and
should be avoided
inhibiting degradation of
bradykinin
Angiotensin II receptor blockers Interferes with rennin-
Alpha-adrenergic blockers
May increase serum
angiotensin system
potassium, increase nausea,
without inhibiting
dysgeuisa, and salt
degradation of
substitutes should be
bradykinin
avoided
Blocks the vascular
Nausea, vomiting, diarrhea,
muscle response to
and mouth dryness are all
sympathetic stimulation;
common side effects and
reduces stroke volume
natural licorice should be
avoided
30. What are the most common nutritional implications of taking hydrochlorothiazide?
Hydrochlorothiazide is a diuretic that decreases blood volume by increasing urinary
output. It makes the person thirsty and causes dehydration. It also causes people to lose
some nutrients through urinary output.
31. Mrs. Anderson’s physician has decided to prescribe an ACE inhibitor and an HMGCoA
reductase inhibitor (Zocor). What changes can be expected in her lipid profile as a
result of taking these medications?
ACE inhibitors reduce blood pressure by increasing the amount of salt and water the
body retains. HMGCoA reductase inhibitor will decrease total cholesterol. The Zocor
will kick start the LDL receptors in the liver and will in turn lower the plasma
concentration of cholesterol. The combination of these medications will decrease her
lipid profile.
32. How does an ACE inhibitor work to lower blood pressure?
An ACE inhibitor lowers blood pressure by decreasing peripheral vascular resistance.
They increase the amount of salt and water the body retains allowing for more stroke
volume and overall a lower blood pressure.
33. How does a HMGCoA reductase inhibitor work to lower serum lipid?
HMGCoA reductase inhibitors work to decrease total cholesterol and in turn serum
lipid, by inducing the expression of LDL receptors in the liver. This in turn increases the
catabolism of plasma LDL and lowers the plasma concentration of cholesterol. It
contains eight transmembrane domains.
34. What other classes of medications can be used to treat hypercholesterolemia?
Although not specific classes of medication, diet and exercise will help maintain a
healthy body weight. It is also important that smoking be eliminated from the lifestyle.
Medications that some people go on include drugs to help lower blood cholesterol
levels such as statins.
35. What are the pertinent drug-nutrient interactions and medical side effects for ACE
inhibitors and HMGCoA?
ACE inhibitors have potential food-drug interactions and side effects of hypotension
especially in elderly patients, it can worsen renal function, hyperkalemia, dysgeusia,
causes dry, nonproductive cough. One should also avoid salt substitutes if on this
medication. For HMGCoAs, the most common side effects are raised liver enzymes and
muscle problems.
36. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic term.
Possible nutrition problems from taking these two medications where the biggest one
would be dry mouth where poor appetite would suffice. It would be hard to eat things
and keep up with the recommended diet.
37. What are some possible barriers to compliance?
If the patient does not wish to take medication, it is important to inform Mrs. Anderson
of all the benefits the medications will have on her health. Hopefully, by saying as she
begins to lose weight, she may lessen the dose needed, and hopefully not need either
medication in the future.
38. Select two high-priority nutrition problems and complete PES statements for each.
-
High lipid diet related to poor dietary intake and high lipid consumption as
evidenced by the 24-hour recall and lab results of low HDL, high LDL and very high
total cholesterol.
-
Poor nutrition intake related to high caloric intake as evidenced by the 24-hour
recall, high BMI and Stage 2 hypertension.
39. Mrs. Anderson asks you, “A lot of my friends have lost weight on that Dr. Atkins diet.
Would it be best for me to follow that for awhile to get this weight off?” What can you
tell Mrs. Anderson about the typical high-protein, low-carbohydrate approach to weight
loss?
The typical high-protein, low-carbohydrate diets do get the weight off fast, but it
normally does not stay off. The diet is mostly a water weight loss. This diet style also
tends to be a higher lipid diet, since it does ask to eat more protein than normal and not
necessarily lean protein. Our bodies crave carbohydrates for energy, and if we are
starving our body of this, they will start to get the energy from else where, that is not a
good way to start off when you are hypertensive already.
40. When you ask Mrs. Anderson how much weight she would like to lose, she tells you she
would like to weigh 125, which is what she weighed most of her adult life. Is this
reasonable? What would you suggest as a goal for weight loss for Mrs. Anderson?
No, I feel that Mrs. Anderson who is 5’6” tall should have a target goal weight around
130 pounds and this number came from the Hamwi method where women start off
with 100 pounds and add 5 pounds for every inch over 5’ tall. Mrs. Anderson should,
however start with smaller goals. I would say start with a ten pound goal to begin and
then go from there.
41. How quickly should Mrs. Anderson lose this weight?
Mrs. Anderson should be losing weight around 1-2 pounds/week. This is the safest way
to lose weight.
42. For each of the PES statements that you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the etiology).
I would like for Mrs. Anderson to reduce her lipid intake drastically. This can be done
doing small things such as changing from 2% milk down to 1% or even better skim
milk. Try to use spray butter instead of margarine and choose fat-free dressing options
over the others. I would hopefully share these goals through nutrition education where
we could set up a plan together of what could be done to reduce lipid intake.
I would also like for Mrs. Anderson to reduce the amount of sodium that is eaten. This
can be done by not adding any extra salt once they are at the dinner table, and try to cut
out salt when preparing the food. Try using other herbs and spices to flavor the food
instead of salt. This can be done through nutrition education as well or if possible, a
cooking class where the chef can lay out the importance of using different herbs and
spices.
43. Identify the major sources of saturated fat and cholesterol in Mrs. Anderson’s diet. What
suggestions would you make for substitutions and/or other changes that would help
Mrs. Anderson reach her medical nutrition therapy goals?
The major sources of saturated fat and cholesterol in Mrs. Anderson’s diet are found in
the morning snack of a glazed donut, the regular Ranch style salad dressing, and the
margarine put on both the oatmeal, baked potato, and glazed carrots. There is also
excess fat in the 2% milk. Substitutions and/or changes that could help reach her goals
would be to change 2% milk down to skim or 1%. Get spray butter to minimize the
amount of butter being used. Use fat-free salad dressing options and trade in the
morning snack of a donut to something more nutritious and fiber filled such as a piece
of fruit or toast and peanut butter.
44. Assuming that the foods in her 24-hour recall are typical of her eating pattern, outline
necessary modifications you could use as a teaching tool.
Foods
Modifications/Alternative(s) Rationale
Coffee (3 c/day)
Lower the amount of coffee
Coffee does not satisfy
down to one or two cups of
thirst, where as water
coffee a day
satisfies thirst and
improves the body
quality and brain
function
Oatmeal (w/margarine &
Decrease the amount of sugar
sugar) or Frosted Mini-Wheats
and margarine that is used, use lipid being consumed as
a spray butter instead
Decrease the amount of
well as the amount of
sugar to help with
weight loss
2% low fat milk
Orange juice
Change to 1% milk or even
Lessen the amount of
skim if possible
lipid consumed
Get the calcium fortified
Increase in calcium in
orange juice
the diet, especially for
an aging woman
Glazed donut
Cake donut if a donut is
A plain cake donut
needed, or whole wheat toast
would be less fat, whole
with peanut butter or a piece
wheat toast would be
of fruit for sweetness
more fiber filled and
improve satiety then, a
piece of fruit would help
crave a sweet tooth, and
yet be nutrient rich
Canned tomato soup
Saltine crackers
Make the soup with water or
Decrease the lipid
1%/skim milk instead
content
Get the low-salt crackers
Lessen the sodium
intake
Diet cola
Water or crystal light
Increase in possibility of
nutrients
12 oz bottle regular beer
Baked chicken
If alcohol is needed, then drink
Lessen the amount of
light beer
calories consumed
Grill the chicken
Less calories in the
baking process and the
chicken can be rubbed
with less sodium then
and more taste can be
given using lemon juice
or different spices
Baked potato (w/ 1 tsp butter,
Use spray butter instead and
Decrease lipid and
salt & pepper)
only use pepper
sodium intake
Carrots
Cut out the glazing and
Decrease the lipid and
sprinkle with pepper or
sodium intake
cayenne pepper for a kick
Salad w/ranch style dressing
Ice Cream
Use a light/fat-free ranch
Decrease the lipid
dressing instead
intake
Eat fat-free frozen yogurt
Decrease the lipid
intake
45. What would you want to reevaluate in 3 to 4 weeks at a follow-up appointment?
I would want to reevaluate a new 24-hour recall to see how the diet recommendations
are coming. I would also want to see if any weight was lost within the last 3-4 weeks. I
would want to see how the new diet compared with the old one and see what else can
be improved.
46. Evaluate Mrs. Anderson’s labs at 6 months and then at 9 months. Have the biochemical
goals been met with the current regimen?
The overall total cholesterol readings have greatly improved where the HDL is
increasing and the LDL is decreasing causing the ratio to get closer to where it is
supposed to be. Although they are not at target, they are getting better. Both of the
apolipoproteins are in their target range now as well. Overall, the biggest issues are
getting better, which is very important.