Erin Baas
KNH 411
Case 6 Hypertension & CVD
1. Define blood pressure.
During the contraction and relaxation stages in the ventricles of the heart, blood
pressure is what is measured when looking at how much force is exerted on the walls of
the blood vessels by the blood pumping through them.
(Nutrition Therapy and pathophysiology page 286)
2. How is blood pressure normally regulated in the body?
Blood pressure is regulated in the body through the sympathetic nervous system,
renin-angiotensin-aldosterone and the renal function.
(Nutrition Therapy and pathophysiology page 286)
3. What causes essential hypertension?
Essential hypertension has no cause.
(Nutrition Therapy and pathophysiology page 288)
4. What are the symptoms of hypertension?
Typically there are no symptoms of hypertension.
(Nutrition Therapy and pathophysiology page 288)
5. How is hypertension diagnosed?
Hypertension goes undiagnosed in the early stages a lot of the time, but looking
at blood pressure can be an indicator.
(Nutrition Therapy and pathophysiology page 288)
6. List the risk factors for developing hypertension.
Lifestyle factors (such as excess sodium and alcohol, low potassium diet), lack of
exercise, smoking, excess stress, and obesity are all common risk factors of
hypertension.
(Nutrition Therapy and pathophysiology page 288)
7. What risk factors does Mrs. Anderson currently have?
Mrs. Anderson has a number of risk factors. She is overweight, consumes
alcohol, was a smoker in the past, and has excess sodium in her diet.
8. (Nutrition Therapy and pathophysiology page 289)
Category
Systolic BP
Diastolic BP
Normal
<120
and
<80
Prehypertension
120-139
or
80-89
Hypertension Stage 140-159
1
or
90-99
Hypertension Stage ≥160
2
or
≥100
9. Given these criteria, which category would Mrs. Anderson’s admitting blood pressure
reading place her in?
This criteria places Mrs. Anderson in the category of Hypertension Stage 2.
10. How is hypertension treated?
Hypertension is treated through weight reduction, physical activity, nutrition
therapy, and pharmacological interventions. Through this treatment, blood pressure will
be reduced which will also reduce the risk for CVD and renal disease.
(Nutrition Therapy and pathophysiology page 288)
11. Dr. Thornton indicated in his admitting note that he will “rule out metabolic
syndrome.” What is metabolic syndrome?
Metabolic syndrome is a whole group of risk factors including abdominal obesity,
insulin resistance, dyslipidemia, hypertension, and prothrombotic state.
12. What factors found in the medical and social history are pertinent for determining
Mrs. Anderson’s CHD risk category?
To determine Mrs. Anderson’s CHD risk, factors that need to be looked at include
her smoking history, what social activities she takes part in, her family medical history,
her blood pressure, and how physically active she is.
13. What progression of her disease might Mrs. Anderson experience?
If she continues to live her unhealthy lifestyle, her blood pressure will most likely
increase, causing her to gain even more weight, which could potentially lead to obesity
and type two diabetes.
14. What are the most recent recommendations for nutrition therapy in hypertension?
Explain the history of and rationale for the DASH diet.
The most recent recommendations involve teaching the patient how to change
their lifestyle by making changes in their diet (less sodium), more physical activity,
weight loss, no smoking, and lowering alcohol consumption. Following the DASH diet
can really help a patient to make these lifestyle changes. The DASH diet came about
through studies done in the 1990s. The outcome of these studies showed that a diet
lower in saturated fat, cholesterol, and total fat reduced blood pressure. These studies
also showed that a diet with a consumption of no more than 1500 mg of sodium a day
significantly reduces blood pressure. This diet is rich in magnesium, potassium, and
calcium through eating lots of fruits, vegetables, low-fat dairy foods, whole grains, fish,
poultry, and nuts.
(Nutrition Therapy and pathophysiology page 295)
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 no more than
1500 mg/day. This is controversial because it is a challenge to meet this. Also not all
diets stick to this amount, there are some diets that recommend no more than 2400
mg/day, and some no more than 3300 mg/day.
16. What are therapeutic lifestyle changes? Outline the major components of the
nutrition therapy interventions.
Therapeutic lifestyle changes are “diets low in saturated fat and cholesterol and
rich in fruits, vegetables, and grain products that contain some types of dietary fiber,
particularly soluble fiber, may reduce the risk of heart disease.” (Nutrition Therapy and
Pathophysiology, page 308)
The major components of nutrition therapy interventions include weight loss,
physical activity, total dietary fat, saturated fat, trans fatty acids, monounsaturated fat,
omega 3-fatty acids, polyunsaturated fatty acids, cholesterol, nuts, plants/sterols, folate,
and nutrition education and/or nutrition counseling.
17. The most recent recommendations suggest the therapeutic use of stanol esters.
What are they, and what is the rationale for their use?
Stanol esters are used to lower the amount of cholesterol absorbed in the body.
(Nutrition Therapy and pathophysiology page 315)
18. Calculate Mrs. Anderson’s body mass index (BMI).
Mrs. Anderson’s BMI is 25.1. She falls into the category of overweight, as the
range for this category is 25-29.9.
19. What are the health implications of this number?
Being in the category for overweight increases her risk for hypertension, obesity,
and diabetes.
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 requirements (REE) are between 1569.75 1353.75 kcals. The equation I used to determine this was the World Health Organization
(WHO) formula. I chose to use this formula because the only difference between it and
the Harris-Benedict formula is that the WHO formula does not take into account the
client’s height. I didn’t feel it was necessary to take into account Mrs. Anderson’s height.
She is 5’6”, which is around or higher than an average height for a female. If she were
much shorter and overweight, or much taller and underweight, I think it would effect her
energy needs more.
Mrs. Anderson’s total energy needs (TEE) are 1404.88 kcals. When calculating
this, I chose to use the TEE equation for overweight/obese females 19 years and older,
because Mrs. Anderson’s BMI places her in the overweight category.
21. How many calories per day would you recommend for Mrs. Anderson?
Mrs. Anderson is currently overweight. She is looking to lose some of that
weight to try and live a healthier lifestyle. To maintain her current weight, she should be
eating around1400-1450 kcals/day. I would recommend that for now she take in around
1350 kcals/day, but no lower than 1300. This way, she can lose weight at a proper
pace, while not feeling too low on energy each day.
22. Determine the appropriate percentages of total kilocalories from carbohydrate,
protein, and lipid.
For Mrs. Anderson I would recommend 65% carbs, 30% protein, and 5% lipid.
For a healthier individual, I would recommend 60, 30, and 10. However, Mrs. Anderson
has higher cholesterol, so lowering her lipid intake will only continue to help her health.
23.
Food
Potassiu
m
Sodium
Magnesiu
m
Calcium
Total fat
Saturated
fat
Cholester
ol
Fiber
Coffee
252.5 mg
11.4 mg
17.5 mg
12.1 mg
.1 g
0
0
0
Oatmeal
123.2 mg
225.5 mg
50 mg
136.4 mg
4.67 g
.81 g
.05 mg
2.9 g
Mini
wheats/2
% milk
438.2 mg
57.8 mg
105.4 mg
167.7 mg
3.6 g
1.5 g
9.8 mg
7.8 g
Glazed
donut
45.9 mg
180.9 mg
10 mg
3.72 mg
10.31 g
2.67 g
14.4 mg
0.7 g
Orange
juice
480.8 mg
7.5 mg
25.9 mg
28.1 mg
.1 g
0
0
.6 g
10
saltines
0
300 mg
0
0
3g
0
0
0
Campbell’
s soup
w/milk
604.9 mg
1109.4
mg
25.1 mg
185.7 mg
6.6 g
3.1 g
22.6 mg
.5 g
Baked
chicken
286.7 mg
420.8 mg
40 mg
37.2 mg
17.58 g
4.42 g
107.85
mg
0.5 g
Diet cola
7.4 mg
14.8 mg
0
7.4 mg
.1 g
0
0
0
Glazed
carrots
756.1 mg
552.8
45 mg
136.4 mg
25.78 g
4.78 g
.05 mg
8.4 g
Potato
1603 mg
811.4 mg
83.98 mg
48.3 mg
11.8 g
7.4 g
30.5 mg
6.6 g
Beer
236 mg
21.5 mg
65 mg
37.2 mg
0
0
0
0
Salad
316.6 mg
479.1 mg
32.4 mg
58.6 mg
23.9 g
3.7 g
12.3 mg
1.8 g
Butter
pecan ice
cream
133 mg
110 mg
14 mg
99.2 mg
9g
4.5 g
20 mg
0.7 g
Totals
3943.1
mg
3819.8
mg
305.48
mg
610 mg
116.54 g
32.88 g
217.55
mg
30.5 g
24. What nutrients in Mrs. Anderson’s diet are of major concern to you?
I think every nutrient in Mrs. Anderson’s diet is of major concern. The nutrient
that stands out the most, however, is her sodium intake. Someone with Hypertension
stage 2 should really be trying not to take in any more than 1500 mg a day, she is taking
in more than 3500 mg/day. She should also really be trying to increase her potassium
intake, as this could help to lower her blood pressure. It is also recommended for
individuals to take in no more than 200 mg of cholesterol per day. Since Mrs. Anderson
is looking to lower her blood pressure and avoid heart disease, lowering her cholesterol
intake should really be of concern to her. Her calcium intake is also something to really
take a look at. She is over 50, so her calcium levels are already going to be low, so the
closer she can get to the RDA, the better.
25. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic term.
26. (Nutrition Therapy and Pathophysiology, pages 284-300)
Parameter
Normal
Value
Patient’s
value(admis
sion)
Patient’s
value (3
months)
Patient’s
value (6
months)
Reason for
abnormality
Nutrition
implication
Glucose
70-110 mg/dL
92 mg/dL
90 mg/dL
96 mg/dL
N/A
N/A
BUN
8-18 mg/dL
20 mg/dL
15 mg/dL
22 mg/dL
She is not
taking in
enough fluids
to remove
nitrogen from
her system
This could
lead to kidney
problems/me
an they are
not
functioning
properly
Creatine
.6-1.2 mg/dL
.9 mg/dL
1.1 mg/dL
1.1 mg/dL
N/A
N/A
Total
Cholesterol
120-199
mg/dL
270 mg/dL
230 mg/dL
210 mg/dL
Too much
cholesterol,
fat, and
sodium in her
diet.
This could
lead to heart
disease,
diabetes,
obesity, etc.
HDLcholesterol
>55 mg/dL
(women)
>45 mg/dL
(men)
30 mg/dL
35 mg/dL
38 mg/dL
Not enough
healthy
cholesterol in
diet
More HDL will
help to lower
blood
pressure. Not
enough could
lead to
atherosclerosi
s.
LDLcholesterol
<130 mg/dL
210 mg/dL
169 mg/dL
147 mg/dL
Too much
unhealthy
cholesterol in
the diet
Could lead to
heart disease,
hypertension,
etc.
Apo A
101-199
mg/dL
(women)
94-178 mg/dL
(men)
75 mg/dL
100 mg/dL
110 mg/dL
Over time she
has been
increasing her
intake of
healthy fats
In the correct
range, Apo A
helps
transport
lipids
Parameter
Normal
Value
Patient’s
value(admis
sion)
Patient’s
value (3
months)
Patient’s
value (6
months)
Reason for
abnormality
Nutrition
implication
Apo B
60-126 mg/dL
(women)
63-133 mg/dL
(men)
140 mg/dL
120 mg/dL
115 mg/dL
Overtime has
been
decreasing
amount,
which is
better.
HIgher
amounts
could lead to
plaques,
which could
cause heart
disease.
Triglycerides
35-135
(women)
40-160 (men)
150 mg/dL
130 mg/dL
125 mg/dL
Has been
lowering
triglycerides,
better diet.
Staying in the
range
reduces risk
of heart
disease.
27. Interpret Mrs. Anderson’s risk of CAD based on her profile.
Based on Mrs. Anderson’s profile, she definitely has a high risk of CAD. She has
a high sodium, cholesterol, and fat intake. High intake of these nutrients are known to
clog blood vessels/arteries, which could potentially lead to a number of heart diseases.
28. What is the significance of apolipoprotein A and apolipoprotein B in determining a
person’s risk of CAD?
Having the appropriate amount of Apo proteins A and B will lead to cellular
stability and proper cell binding. Too much or too little of these proteins will cause
instability in bodily processes, which overtime could lead to cardiovascular problems.
(Nutrition therapy and pathophysiology, page 284)
29. (Nutrition Therapy and Pathophysiology, page A-19)
Medications
Mechanism of action
Nutritional implications
Diuretics
inhibits sodium, chloride, and
potassium. Increase urination.
Lowers blood pressure
Beta-blockers
Block receptors in the heart to
decrease rate and cardiac output.
Used to treat hypertension, lowers
blood pressure
Calcium-channel blockers
Affect the movement of calcium,
causing the blood vessels to relax,
reducing vasoconstriction
Used to treat hypertension, lowers
blood pressure
ACE inhibitors
Competitively block the conversion
of angiotensin I into angiotensin II
which improves vasodilation.
Used to treat hypertension, lowers
blood pressure
Angiotensin II receptor blockers
Proinflammatory
Without them plaque development
could occur
Medications
Alpha-adrenergic blockers
Mechanism of action
improves blood flow, opens up
blood vessels/relaxes muscles
Nutritional implications
Lowers blood pressure
30. What are the most common nutritional implications of taking hydrochlorothiazide?
Taking hydrochlorothiadize helps to lower blood pressure and help drain the
kidneys of excess water.
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?
As a result of these medications, Mrs. Anderson’s blood pressure will most likely
drop significantly overtime. The Zocor will help with her excess cholesterol, as long as
she is also controlling the cholesterol in her daily diet as well. The ACE inhibitor will help
with vasodilation, which will help open up her blood vessels, helping to avoid excess
lipid blockage. (Nutrition Therapy and Pathophysiology, page 291)
32. How does an ACE inhibitor work to lower blood pressure?
ACE inhibitors are vasodilators that decrease peripheral vascular resistance by
interfering with the production of angiotensin II from angiotensin I, which all together
works to lower blood pressure.
33. How does HMGCoA reductase inhibitor work to lower serum lipid?
HMGCoA reductase inhibitors work to lower serum lipid by reducing the amount
of cholesterol synthesis that takes place.
(http://cardiovascres.oxfordjournals.org/content/49/2/281.full)
34. What other classes of medications can be used to treat hypercholesterolemia?
Most of the time, high cholesterol levels and be treated by a healthy diet and
exercise However, if this is not enough, medications such as statins, lovastatin,
pravastatin, rosuvastatin, simvastatin, atorvastatin, and fluvastatin.
(http://www.umm.edu/altmed/articles/hypercholesterolemia-000084.htm)
35. What are the pertinent drug-nutrient interactions and medical side effects for ACE
inhibitors and HMGCoA?
Possible food/drug interactions/side effects for ACE inhibitors are hypotension,
especially in the elderly. Along with hyperkalemia, dysgeusia, and can cause problems
in renal function. HMGCoA inhibitors can cause liver damage.
(Nutrition Therapy and Pathophysiology, page 291)
36. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic term.
37. What are some possible barriers to compliance?
Some barriers to compliance include inadequate health literacy, strategy,
financial constraints, cultural differences, religious beliefs, family dynamics, emotional
concerns, lack of motivation, inadequate, teaching time, poor communication, and
logistics.
38. Select two high-priority problems and complete PES statements for each.
1. Hypertension related to excess sodium as evidenced by diet and lab results.
2. Overweight related to high lipid and sodium intake as evidenced by physical
inactivity and diet.
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?
This diet will help her to lose a great deal of water weight at first from a lack of
carbohydrates in the diet. However, if she begins eating carbohydrates again like she
used to, she will gain all of the weight back very quickly. This weight fluctuation is not
good for one’s health. This kind of diet can also lead to ketosis, which is kidney failure.
Also eating a lot of these high protein foods can cause an increase in cholesterol, which
would not help her in lowering her blood pressure.
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?
It is reasonable if she is willing to take a long period of time to complete this
amount of weight loss. She would need to remain mentally patient and stay motivated to
complete this goal. For Mrs. Anderson I would suggest setting a goal for a weight loss of
about 15-20 pounds. If she can complete this goal, I think she could become even more
motivated to get down to 125 lbs. She needs to find out what she is capable of when it
comes to changing her diet and lifestyle.
41. 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
etiology).
1. Work to educate Mrs. Anderson on how she can lower her daily sodium intake.
Help her to learn how to follow the DASH diet.
2. Give Mrs. Anderson the knowledge on how to decrease her lipid intake and
increase physical activity each day to encourage weight loss.
42. 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 are from baked chicken, potatoes, ice cream,
glazed doughnut, and glazed carrots. The major sources of cholesterol in her diet are
baked chicken, glazed carrots, glazed doughnut, and butter. One substitution I would
make right away is instead of ice cream, mix some greek yogurt with fruit. I would also
suggest to get leaner chicken, and to eat the carrots without the glaze because the
glaze is what adds so much cholesterol and saturated fat.
43.
Foods
Modification/Alternatives
Rationale
Coffee (3 c/day)
Reduce to 1-2 cups a day
Caffeine affects energy levels
(high/low)
Oatmeal (w/margarine & sugar) or
frosted mini wheats
Instead of using margarine/sugar,
improve taste with cinnamon
Cinnamon adds a lot of flavor and
health benefits
2% low-fat milk
Switch to 1% or skim milk
Lowers fat intake
Orange juice
Don’t drink in excess, limit to 1 cup
Orange juice has good health
benefits, but can be high in sugar
Glazed donut
Substitute with piece of toast & jelly
or a bagel
Donuts are very high in
lipid/sodium/cholesterol. Toast or
bagel would be much less in all
three.
Canned tomato soup
Vegetable soup
less sodium
Saltine crackers
pistachios (unsalted)
Much less sodium, still a lot of flavor
Diet cola
Water with crystal light
Less sugar, still have flavor
12 oz bottle regular beer
Light beer or glass of red wine
Less calories, glass of wine has
antioxidants
Baked chicken
Leaner chicken
Less sodium/cholesterol
Baked potato (w/ 1 tbsp butter, salt,
pepper)
1 tsp butter, no salt or salt substitute
Less sodium/cholesterol
Carrots
Don’t use glaze
Less lipid/sodium/cholesterol
Salad w/ranch-style dressing
Use lighter dressing
Less lipid
Foods
Ice cream
Modification/Alternatives
substitute greek yogurt with fruit
Rationale
Less lipid, more protein and
vitamins
45. What would you want to reevaluate in 3 to 4 weeks at a follow up appointment?
In a follow up appointment with Mrs. Anderson I would want to reevaluate how
she thinks she is following her diet plan and if it matches lab results. This would show
whether or not she understands the changes she needs to make and if she has been
motivated to make those changes. I would want to look at her blood pressure, sodium,
cholesterol, and lipid intakes most. Looking at these intakes would prove whether or not
she is having trouble sticking to her plan.
46. Evaluate Mrs. Anderson’s labs at 6 months and then at 9 months. Have the
biochemical goals been met with the current regimen?
This regimen has definitely been working. Improvements can definitely be made,
but for the most part, she has been lowering in places she needs to lower in, and
increases in areas that needed to be increased in.