Case Study #4: Hypertension and Cardiovascular Disease

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1 Helen Jang Tara Hooley John K Rhee Case Study #4: Hypertension and Cardiovascular Disease 7. What risk factors does Mrs. Sanders currently have? The risk factors that Mrs. Sanders has are high blood pressure at 160/100mm/Hg (normal 120/80mm/Hg), which is considered hypertension (HT) stage 2. She also has a high intake of sodium which can further exacerbate her HT. She is also at risk for atherosclerosis because her cholesterol is high. Her cholesterol ratio also puts her at risk because her HDL levels are too low and her LDL levels are too high. Her HDL levels are too low at 38 (ideal for women is >55). Her LDL levels are 147 which is in the high region. Mrs. Sanders is overweight with a BMI of 25.8 which increases the risk factors for disease. Mrs. Sanders also has a family history of HT, her mother died of a myocardial infarction (MI) related to HT. She has a history of smoking two packets of cigarettes per day which also increases the risk of cardiovascular disease. Being an African American also puts Mrs. Sanders at greater risk. 13. Briefly describe the DASH eating plan. The DASH diet plan was devised, researched and sponsored by the National Heart, Lung, and Blood Institute. DASH was designed to lower blood pressure without the use of medication, however, DASH also helps improve lipid blood levels and reduce cardiovascular disease.dash focuses on eating foods low in saturated and trans fat, low in cholesterol, low fat or non fat dairy products. DASH encourages increasing consumption of vegetables and fruits which will also increase fiber. A typical day in the 2000 kcal DASH diet consists of 7 8 servings of grains, 4 5 servings of vegetables, 4 5 servings of fruits, 2 3 servings of low fat or non fat dairy, 2 servings of lean meat poultry, or fish, or less (3oz serving), 4 5 servings of nuts, seeds, or beans, 2 3 servings of fats or oils. Sweets can be incorporated up to 5 tablespoons of sweets per week. The nutritional content of the foods on the DASH diet are rich in potassium, calcium, and magnesium as these three minerals have an inverse relationship with HT. DASH recommends no more than two alcoholic drinks per day for men and no more than one alcoholic drink per day for women.

2 15. Lifestyle modifications reduce blood pressure, enhance the efficacy of antihypertensive medications, and decrease cardiovascular risk. List lifestyle modifications that have been shown to lower BP. The DASH diet can lower blood pressure. Other lifestyle modifications that can lower BP are reducing sodium intake, participating in regular 30 minute sessions of physical activity, losing weight or maintaining a healthy weight, managing and reducing stress, avoiding tobacco/ smoking, limiting alcohol to 1 drink a day for women and 2 drink a day for men, and using up as many kcal as you consume. A modest weight loss of 5% 10% would reduce the risk of these diseases. 16. What are the health implications of Mrs. Sanders BMI? Mrs. Sanders BMI of 25.8 falls in the overweight range; however, if she continues her high fat diet she could end up putting on more weight and becoming obese. There are many health implications currently associated with being overweight. Mrs. Sanders BMI increases her risk of Coronary Heart Disease, Type 2 DM, dyslipidemia, stroke, and respiratory problems including sleep apnea. Mrs. Sanders is also at increased risk of musculoskeletal disorders like osteoarthritis, and some cancers (endometrial, breast and colon). These conditions cause premature death and substantial disability. Being overweight also increases the risk of liver and gallbladder disease. A modest weight loss of 5% 10% would reduce the risk of these diseases. Mrs. Sanders also risks exacerbating her HTN if she does not lose weight which will start to put additional pressure on her kidneys and could lead to renal disease.. The more overweight a person is, the higher the risk of disease. Her health status could deteriorate if she continues with her current diet. Her diet consists of high sugary and salty foods such as glazed donuts, canned soup, 10 saltine crackers, baked potato with tbsp butter and salt, glazed carrots, and 2 cups of butter pecan ice cream. This combination of sugar and salt could further exacerbate her high blood pressure and cause more weight gain. 17. Calculate Mrs. Sanders s resting and total energy needs. Mrs. Sander s resting energy expenditure is calculated using the Harris benedict Equation. Her BMI = 25.8 therefore Mrs. Sanders actual weight of 160 lbs and height 5ft 6 can be used. 160lbs /2.2= 72.7kg 5ft 6 = x 2.54 = cm Female = ( X weight) + (1.8 X height) (4.7 x age)

3 = (9.6 x 72.7kg) + (1.8 x ) (4.7 x 54years) = 1411kcal REE Mrs. Sanders walks for 30 minutes 4/5 times a week so her physical activity factor is kcal x 1.4= 1975kcal 1411kcal x 1.5 = 2117kcal Mrs. Sanders total energy requirement is 1975kcal 2117kcal/ day. The thermic effect of food can also contribute up to 10% total energy expenditure. 18. What nutrients in Mrs. Sanders s diet are of major concern to you? Calculate calories, total fat, saturated fat and sodium quantities for every food item in her 24 hour recall. Food / Drink Serving Size Calories Total Fat (g) Saturated Fat (g) Sodium (mg) AM Meal Coffee Black 1 c Oatmeal (1tsp margarine, 2tsp sugar) 1 Instant packet Milk low fat 2% ½ cup Orange Juice 1c Snack Coffee 2 c Glazed Donut Lunch Campbell s Tomato Bisque Soup with milk 1 can Saltines Diet Cola 1 can PM Meal Baked Chicken 6 oz

4 no skin, seasoned with salt, pepper & garlic Baked Potato 1tbsp butter, salt & pepper Glazed Carrots 1tsp sugar, 1tsp butter Dinner Salad lettuce, spinach, croutons, cucumbers 1 large c c Ranch Style Dressing 3 tbsp Beer 2 cans HS Snack Butter Pecan Ice Cream 2 c Totals 3156 Calories 141.5g Fat 54.51g Saturated Fat 5153mg Sodium From calculating Mrs. Sanders 24 hour recall, her calorie, fat, saturated fat, and sodium intakes are all much higher than recommended. In particular her sodium intake is worrying as it could exacerbate her HT. The recommended sodium intake is 1500mg per day for adults over 51 years of age. The recommended amount of fat intake is no more than 25 35% of calories. As Mrs. Sanders should be eating between 1975kcal 2117kcal/ day then her fat intake should be around 65g 75g/ day. Mrs Sanders consumed over 140g of fat, nearly double what she needs. Saturated fat intake should be no more than 7% of calories. This equates to kcal 138kcal which is around 20g/ day. Mrs. Sanders consumption was also over double this recommendation. If she carries on consuming this amount of fat and calories, she will gain weight which will further increase her chance of a cardiovascular incident. 19. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic terms. Excessive sodium intake over a 24 hour period which increases the risk of HT.

5 Excessive sodium intake over 24 hour period which increases risk of renal disease. Excessive intake of calories, fat and saturated fat during a 24 hour period which over an extended period of time will lead to unintended weight gain and increase the risk of CAD. 21. Interpret Mrs. Sanders s risk of CAD based on her lipid profile. Mrs. Sanders lipid profile shows she has a high risk CAD due to dyslipidemia, which means her lipid profile increases the risk of atherosclerotic development. Dyslipidemia is usually a condition in which low density lipoprotein (LDL) levels are elevated and high density lipoprotein (HDL) levels are low. Mrs. Sanders has a high LDL level at all three apointments 210mg/dL, 169mg/dL and 147mg/dL. Normal levels are <130mg/dL and LDL >160mg/dL is a risk factor for CAD. Mrs. Sanders HDL is low at 30mg/dL, 35mg/dL and 38 mg/dl, the normal is >55mg/dL. Levels <35mg/dL in a female are considered a risk factor for CAD. This means her ratio of LDL/HDL is high at 7.0, 4.8 and 3.9 at her three appointments. The normal is 3.22 for a female and above 5 is an increased risk factor. HDL offers a protective effect against atherosclerosis. Since HDL removes cholesterol from tissues and returns that cholesterol to the liver, it reduces cholesterol in plaques. Mrs. Sanders also has a high cholesterol level at all three appointments of 270mg/dL, 230mg/dL and 210 mg/dl. Normal levels are mg/dL. Above 240mg/dL in a female is an increased risk factor.triglyceride levels are also high at 150mg/dL.Normal ranges from mg/dL and increased risk factor is above 200mg/dL. 32. PES 1: Excessive intake of saturated and trans fats related to intake of fast food and added butter as evidenced by LDL of 210mg/dL and cholesterol level 270mg/dL through 24 hour recall. PES 2: Excessive Sodium intake related to intake of fast foods and processed foods as evidenced by blood pressure of systolic 160mmHg and diastolic 100mmHg through 24 hour recall. 33. When you ask Mrs. Sanders 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

6 life. Is this reasonable? What would you suggest as a goal for weight loss for Mrs. Sanders? 160 lbs x 10% = 16 lbs weight loss It is not realistic for Mrs. Sanders to lose 35 lbs in a short amount of time. Mrs. Sanders current weight is 160 lbs and the recommended weight loss is 10% of her body weight which will put her at 144 lbs. If Mrs. Sanders sets unrealistic goals, she is more likely to relapse back to her old eating habits as she did previously with following the low sodium diet. For overweight patients, a 10% weight loss provides much more improvement in their morbidities. 34. How quickly should Mrs. Sanders lose this weight? It is recommended to lose 1 2lbs per week. It is more realistic if Mrs. Sanders lose 1lb per week so it can take up to 35 weeks. To achieve this Mrs. Sanders should reduce her daily kcal intake by 500 kcal. Over a week this equates to 3500 kcal which equals 1lb weight loss. If Mrs. Sanders continues her walking then she should decrease 500kcal/day to 1475kcal 1617kcal per day. =1975kcal 500 = 1475kcal =2117kcal 500 = 1617kcal If Mrs. Sanders thinks 500 calories is too much to decrease, we can try to decrease 250 kcals per day instead to 1725kcal 1867kcal per day. =1975kcal 250 = 1725kcal =2117kcal 250 = 1867kcal 35. PES 1: Excessive intake of saturated and trans fats related to intake of fast food and added butter as evidenced by LDL of 210mg/dL and cholesterol level 270mg/dL through 24 hour recall. Goal: Decrease the intake of saturated and trans fats and consumption of fast foods, and butter. Lower LDL levels by alternate diets. To reach this goal, it is recommended to substitute foods with high saturated and trans fats with foods that consist of less fats or mono and polyunsaturated fats.

7 PES 2: Excessive Sodium intake related to intake of fast foods and processed foods as evidenced by blood pressure of systolic 160mmHg and diastolic 100mmHg through 24 hour recall. Goal: Decrease sodium intake from sources of fast foods and processed foods. Lower blood pressure through diet intervention. Consume less sodium in diet in general, by replacing fast foods and processed foods with home made meals, consisting of less sodium and sodium replacement seasonings. 36. Identify the major sources of sodium, saturated fat, and cholesterol in Mrs. Sanders s diet. What suggestions would you make for substitutions and/or other changes that would help Mrs. Sanders reach her medical nutrition therapy goals? Major sources of sodium in Mrs. Sanders diet are through canned tomato soup, saltines, seasoning (chicken). salad dressing, butter pecan ice cream, and beer. Sources of saturated fat is through canned tomato soup, glazed donut, croutons in salad, butter in baked potato and carrots, beer, and ice cream. Instead of consuming canned tomato soup, Mrs. Sanders could make homemade soup using less salt or opt for low sodium soups. Mrs. Sanders could also substitute the salty saltines crackers with low sodium crackers, and reduce the amount of salt she adds to her cooking, for example when seasoning the chicken. By experimenting with different spices instead to add flavor. For the salad dressing, Mrs Sanders could start using a dressing with lower sodium, such as vinaigrette dressing or make a homemade one from yogurt. Adopting the DASH diet, will also help Mrs.Sanders to reduce sodium intake. To reduce her saturated fat intake, Mrs. Sanders could try replacing her glazed donut with a half whole wheat bagel or 1 piece of whole grain toast. Though not too high in saturated fat content, the croutons in her salad could be replaced with nuts or seeds to increase her healthy fat intake but still provide satiety. Mrs. Sanders should also reduce the amount of butter she uses in her cooking, for example on her baked potato and carrots, and eventually maybe even try no butter as her palette adjusts to the different flavor. For the ice cream, she can enjoy a non fat dairy yogurt with fresh fruits instead. For the glazed carrots, maybe she can opt for cooked or raw vegetables. Through the DASH diet, Mrs.Sanders is encouraged to increase her fruit and vegetable intake. The sources of dietary cholesterol Mrs. Sanders is consuming are from animal products such as chicken (around 130mg for 6oz) and butter (1tbsp is 31mg). By reducing the amount of butter Mrs. Sanders adds to foods and reducing her

8 portion size of chicken from 6oz to 3oz (Mrs. Sanders could do this gradually), dietary cholesterol intake would be reduced. Consuming less than 300 mg per day of cholesterol can help maintain normal blood cholesterol levels and consuming less than 200 mg per day can further help individuals at high risk of cardiovascular disease.

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