MNT in a Patient with Diabetes Status Post Myocardial Infarction. MEGAN SOLLOWAY University of Maryland Dietetic Intern March 31, 2015

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1 MNT in a Patient with Diabetes Status Post Myocardial Infarction MEGAN SOLLOWAY University of Maryland Dietetic Intern March 31, 2015

2 ST-elevated Myocardial Infarction (STEMI) Blood clot blocks blood flow Death of heart tissue downstream ST-elevation in echocardiogram

3 ST-elevated Myocardial Infarction (STEMI) Treatment Restore blood flow Surgical removal of clot Stent placement Angioplasty Increase risk hx of diabetes, hyperlipidemia, hypertension, obesity

4 Dietary Interventions Comfort care immediately post-stemi Small frequent meals Transition to Therapeutic Lifestyle Changes (TLC) once stable Nutrition counseling strategies Goal Setting Self-monitoring Problem solving Follow-up with an outpatient clinic for cardiac rehab

5 Non-Traditional Treatment Nutrition supplements Magnesium Carnitine Co-enzyme Q10 Amino Acids Arginine Taurine Herbal Medications Hawthorn Berberine Taurine (cardio-preventative)

6 Nutrition Assessment MEET RK!

7 General Information 56 year-old white female Admitted September 15 th, days in CCU and 2 days in PCU Discharged September 18 th, 2014 Symptoms Sub-sternal chest tightness Bilateral shoulder pain Tingling in fingers Diaphoresis N/V Headache

8 Medical Data Medical hx Obstructive Sleep Apnea Hypertension Hyperlipidemia (w/ statin intolerance) Hypothyroidism Fibromyalgia Chronic Fatigue Syndrome Rheumatoid Arthritis Recent Type 2 Diabetes dx No food allergies or major surgical history

9 Anthropometrics and Nutrition-Focused Physical Findings Notable labs Hgb A1C 10.4% Blood Glucose mg/dl No change in appetite PTA Intentional 34 lb wt loss over 6 years ( First Diet ) Stable over past 6 months Modified diet to improve blood glucose control w/type 2 diabetes dx No RD instruction (personal internet research) Current height 5 3 Current weight 183 lb (83 kg) Ideal Body Weight 115 lb (52.3 kg) % IBW 159% Adjusted body weight 132 lb (60kg) % UBW 102% BMI 30.5

10 Food and Nutrition Related History Outpatient Medications Lantus, Glimepride, Benicar, Janjumet, K-Dur Inpatient Medications Novolog, Lantus, Benicar, Crestor, Plavix, Lovenox, Lopressor, Married w/no children No smoking or EtOH abuse history Retired school teacher Receives social security and supplemental disability benefits Food Prep RK does the food shopping and cooking Does not use a salt shaker Limited Physical Activity r/t Chronic Fatigue

11 Nutrition Diagnosis Food and nutrition related knowledge deficit related to lack of prior nutrition related education (cardiac/diabetes) as evidence by recent STEMI

12 Intervention NUTRITION EDUCATION!

13 Estimated Nutrient Needs Comfort care for first few days Small, frequent meals TLC Diet (NCM) once stable <7% of energy from saturated fat and no trans fats <200mg cholesterol/day 25-35% of calories from fat 50-60% of calories from carbohydrate and 15% from protein 25-30g fiber/day, with 50% coming from soluble fiber Moderate exercise to expend 200 calories per day Source Kcal Protein Fluid Facility Standards Evidence Analysis Library (EAL) Online (NCM) 1200 kcal (BEEx1.2, kcal for 1 lb weight loss/week) 1391 kcal/d (Mifflin St. Jeor) g ( g/kg Adjusted Body Weight) No conclusive recommend ations 1395 kcal 52 g protein (15% of calories) ml/d (25-40 ml/kg Adjusted Body Weight/d) No conclusive recommen dations 1395 ml/kcal (1ml/kcal) 1

14 Nutrition Education MD Consult for Cardiac & Diabetic Diet 3 handouts provided Carbohydrate Counting for People with Diabetes Heart Healthy Nutrition Therapy Physical Activity with Chronic Fatigue Syndrome No prior diet education Discussed food/mood diary for emotional eating MD interruption

15 Nutrition Goals Weight loss (1 lb/week) Improved HgbA1c (<6%) Improved lipid panel (total cholesterol < 200 mg/dl, LDL < 70 mg/dl, HDL > 60 mg/dl, triglycerides < 150 mg/dl).

16 Monitoring and Evaluation WEIGHT, HGBA1C, LIPID PANEL

17 Implications of Findings to Dietetics RD s play a large role in dietary counseling of patients with CVD and diabetes Goal setting Problem solving Self-monitoring Small, meaningful changes Meet the patient where they are! Watch for potential herbal-drug interactions

Disorders of Lipid Metabolism Toolkit Table of Contents

American Dietetic Association Table of Contents 1. Acknowledgements 2. Overview of 3. Medical Nutrition Therapy Protocol Forms for Implementing Disorders of Lipid Metabolism Evidence-Based Guideline a.