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Andrea MyersKNH 4118/28/12Case Study: Hypertension and Cardiovascular DiseaseCase QuestionsI. Understanding the Disease and Pathophysiology1. Define blood pressure. Blood pressure is the force exerted by the blood on the walls of blood vessels. Blood pressure is measured by the systolic blood pressure (the force exerted during the contraction of the ventricles) and the diastolic blood pressure (the force exerted during the relaxation of the blood vessels. When measured, the systolic blood pressure is over the diastolic blood pressure. Blood pressure is measured in millimeters of mercury (mm Hg). (pg. 286)2. How is blood pressure normally regulated in the body?Blood pressure is normally regulated in the body by the homeostatic mechanisms of the body by the volume of the blood, the lumen of the arteries and arterioles, and the force of the cardiac contractions. 3. What causes essential hypertension?There is no known cause of essential (primary) hypertension. It is idiopathic. (pg 288)4. What are the symptoms of hypertension?There are typically no symptoms of hypertension, but hypertension can cause congestive heart failure, kidney failure, myocardial infarction, stroke and aneurisms is left untreated. There may also be vision problems , decreased left ventricular ejection fraction, ventricular arrhythmias and sudden cardiac death. (pg 288) 5. How is hypertension diagnosed?Hypertension is diagnosed when a person’s blood pressure is equal to or greater than 140/90 mm Hg. It is not necessary for both the diastolic and the systolic to be raised to be considered hypertensive. A reading is considered hypertensive whether one reading is elevated or both. 6. List the risk factors for developing hypertension.-age (risk increases with age)-race (more common in African-Americans)-family history -being overweight or obese-not being physically active-using tobacco-too much sodium in diet-too little potassium or Vitamin D in the diet- drinking too much alcohol (more than two drinks a day, sometimes less for women)-stress-certain chronic conditions7. What risk factors does Mrs. Anderson currently have?Mrs. Anderson already has the risk factors of age (being a woman over 50), race (being African-American), family history (her mother dies of MI due to uncontrolled HTN), using tobacco (though she quit a year ago, she was a heavy smoker for 30 years), too much sodium in diet (see dietary analysis), and drinking alcohol. 8. Hypertension is classified in stages based on the risk of developing CVD. Complete the following table of hypertension classification. (pg 289)Blood Pressure mm HgCategorySystolic BP (mm Hg)Diastolic BP (mm Hg)Normal<120and<80Prehypertension120-139or80-89Hypertension Stage 1140-159 or90-99 Hypertension Stage 2>160or>100 9. Given these criteria, which category would Mrs. Anderson’s admitting blood pressure reading place her in?Mrs. Anderson’s admitting blood pressure reading of 160/100 mm Hg would put her in the category of Hypertension Stage 2.10. How is hypertension treated?Hypertension is first treated through lifestyle modifications (exercise, proper diet, quitting smoking, weight reduction) and if that alone does not bring the patient to their goal blood pressure, then they will be put on a medication to help control their blood pressure (to be determined by their physician). If the patient is still not at their target blood pressure, adjustments to the medication can be mad and they may want to consider seeing a hypertension specialist. (pg. 290)11. Dr. Thornton indicated in his admitting note that he will “rule out metabolic syndrome.” What is metabolic syndrome?Metabolic syndrome is a name for a group of risk factors ( being “apple shaped- having an excess of weight around the stomach and upper body, insulin resistance, age, genetics, hormone changes, lack of exercise) that occur together and increase the risk for coronary artery disease, stroke and type 2 diabetes. 12. What factors found in the medical and social history are pertinent for determining Mrs. Anderson’s CHD risk category?The factors found in the medical and social history that are pertinent for determining Mrs. Anderson’s CHD risk category are the fact that she was a heavy smoker up until a year ago, that her mother passed away due to MI related to uncontrolled HTN, and that she does not follow the 4-g Na diet, the fact that she partakes in alcohol consumption on a regular basis (regular beers) and her overweight BMI score. 13. What progression of her disease might Mrs. Anderson experience?Mrs. Anderson may experience atherosclerosis and a heart attack. II. Understanding the Nutrition Therapy14. What are the most recent recommendations for nutrition therapy in hypertension? Explain the history and rationale for the DASH diet.The most recent recommendation for nutrition therapy in hypertension is for the client to reduce sodium, reducing saturated fat and increasing calcium, potassium, fiber and magnesium intake. The DASH (dietary approach to stop hypertension) diet was developed by the NIH in order to lower blood pressure without medication. This diet involves eating a lot of fresh foods (fruits, vegetables), low fat foods and whole grains (as opposed to refined grains). Another aspect is that it is rich in potassium, magnesium, calcium and fiber (which are all proven to lower blood pressure). 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 the treatment of hypertension is that research shows that there is a direct correlation between urinary sodium content and blood pressure. This is a controversial topic because, while the majority of studies do support this idea, there have been some studies that show the opposite (mostly in the elderly). 16. What are the Therapeutic Lifestyle Changes? Outline the major components of the nutrition therapy interventions. Therapeutic Lifestyle Changes are reducing the intake of cholesterol and cholesterol increasing nutrients, such as saturated fats, increasing LDL reducing foods, increase physical activity and weight loss. 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 esters that are similar to cholesterol. They have been shown to help lover LDL levels by interrupting lipid absorption or inhibiting cholesterol synthesisIII. Nutrition AssessmentA. Evaluation of Weight/Body Composition18. Calculate Mrs. Anderson’s body mass index (BMI). BMI= weight (kg)/height (m) ^2Weight (lbs): 160 lbsWeight (kg): 160 lbs x .45 = 72.57 kgHeight (in): 5’6”Height (cm): 66” x 0.0254= 1.68 m72.57 kg/ (1.68m x 1.68m)= 25.7Mrs. Anderson’s BMI is 25.719. What are the health implications of this number?The health implications of this number are that Mrs. Anderson falls into the “overweight” category on the BMI scale. This puts her at risk for developing other diseases. B. Calculation of Nutrient Requirements20. Calculate Mrs. Anderson’s resting and total energy needs. Identify the formula/calculation method you used and explain your rationale for using it. (see attached sheet for calculations)I used the Harris Benedict Equation for a woman who is slightly active for this calculation. 21. How many calories per day would you recommend for Mrs. Anderson?I recommend that Mrs. Anderson eat 2000 calories per day.22. Determine the appropriate percentages of total kilocalories from carbohydrate, protein, and lipid. -CHO: 50-60%= 1000-1200 kcal/day-Protein: 15% = 300 kcal/day-Lipid: 25-35%= 500-700 kcal/dayC. Intake domain23. Using a computer dietary analysis program or food composition table, compare Mrs. Anderson’s “usual” dietary intake to her prescribed diet (DASH/TLC diet). Food ItemPotassiumminimum 4,700 mg/100 mEq)Sodium (maximum 2,400 mg/ 100mEq)Magnesium (500 mg)Calcium (minimum 1,240 mg)Total fat (g)Sat. fat (g)Cholesterol (mg)Fiber (g)Coffee (3c/day)252.511.44%1%0.10.010.00.0Oatmeal (w/margarine and sugar) or Frosted Mini-Wheats134.9294.112%11%2.60.450.03.52% low-fat milk3661007%29%4.83.119.50.0Orange Juice480.87.56%3%0.150.0170.00.57Glazed Donut98434.24%3%19.65.817.91.7Canned tomato soup308.1704.63%5%2.90.994.31.0Saltine crackers27.71931%1%2.00.30.00.54Diet cola0.0400.00.00.00.00.00.012 bottle reg. beer97.214.45%1%0.00.00.00.0Baked chicken476.3770.813%3%15.14.3163.30.0Baked potato (w/1 tbsp butter, salt and pepper)4772941%8%0.120.0320.01.8Carrots (glazed)150.3102.52%2%4.60.850.01.7Salad with Ranch dressing7.1143.60%0%7.81.24.10.044Ice Cream537.9197.934%10%28.517.6107.41.924. What nutrients in Mrs. Anderson’s diet are of major concern to you?I am concerned with her intake of potassium, sodium, magnesium and fiber.25. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. D. Clinical Domain26. Dr. Thornton ordered the following labs: fasting glucose , cholesterol, triglycerides, creatine, 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). ParameterNormal ValuePatient’s valueReason for AbnormalityNutrition ImplicationGlucose70-110 mg/dL92w/in normal limits---BUN8-18 mg/dL20slightly high---Creatine0.6-1.2 mg/dL0.9w/in normal limits---Total Cholesterol120-199 mg/dL270highlower sodium and sat fatHDL-cholesterol>55 (women) mg/dL>45 (men) mg/dL30lowincrease consumption of plant based foodsLDL- cholesterol<130 mg/dL314highdecrese consumption of sat fatApo A101-199 (women) mg/dL94-178 (men) mg/dL75lowincrease plant based foodsApo B60-126 (women) mg/dL63-133 (men) mg/dL140highdecrease sodium and sat. fatTriglycerides 35-135 (women)40-160 (men)150highdecrease consumption of sat fat 27. Interpret Mrs. Anderson’s risk of CAD based on her lipid profile.Mrs. Anderson has an elevated risk of CAD due to her high LDL cholesterol count, low HDL cholesterol count, low Apo A, high Apo B and high triglyceride levels. 28. What is the significance of apolipoprotein A and apolipoprotein B in determining a person’s risk of CAD?Apo A is the protein portion of HDL and Apo B is the protein portion of LDL Buildup of Apo B can cause atherosclerosis and CAD. Apo A helps to clear cholesterol from the blood, not enough of it can cause buildup in the ateries. 29. Indicate the pharmacological differences among the antihypertensive agents listed below.MedicationsMechanism of ActionNutritional ImplicationsDiuretics Urinary output increased, blood volume decreasedLess sodium and water absorption Beta-blockersBlocks B-receptors in heart, decreases heart rate and cardiac outputLower blood pressureCalcium-channel blockersRelaxes blood vessels, decreases vasoconstriction Lower blood pressure, less calcium neededACE inhibitorsInterferes with production of angiotensin II and degradation of bradykinin (vasodilator)Lower blood pressureAngiotensin II receptor blockersInterferes with rennin-angiotensin systems does not interfere with degradation of bradykininLowers blood pressureAlpha-adrenergenic blockersReduces stroke volumeLowers blood pressure30. Why are the most common nutritional implications of taking hydrochlorothiazide?The most common nutritional implications of taking hydrochlorothiazide is that less potassium is needed.31. Mrs. Anderson 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?Due to these changes, her LDL should decrease by 18-55%, her HDL should increase by 5-10% and her triglycerides should decrease by 7-10%32. How does an ACE inhibitor work to lower blood pressure?ACE inhibitors inhibit angiotensin II from forming from angiotensin I by competitively blocking the c enzyme. This causes vasodilation and a decrease in vasopressin release resulting in lower blood pressure.33. How does a HMGCoA reductase inhibitor work to lower serum lipid?A HMGCoA affects the rate limiting step of cholesterol synthesis. It helps to decrease synthesis and lowering serum lipid. 34. What other classes of medications can be used to treat hypercholesterolemia?Other classes of medications that can be used to treat hypercholesterolemia are Bile Acid Sequestrants, Nicotinic Acid and fibric acids. 35. What are the permanent drug-nutrient interactions and medical side effects for ACE inhibitors and HMGCoA?-ACE inhibitors: hypotension, decreased renal function, hyperkalemia, dysgeusia, dry, non productive cough-HMGCoA: myopathy, increased liver enzymes36. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. E. Behavioral-Environmental Domain37. What are some possible barriers to compliance?Some possible barriers to compliance are not having enough time, not having enough energy, not being motivated to change, the taste of the diet (low-sodium) and the client not being ready. IV. Nutrition Diagnosis38. Select two high-priority nutrition problems and complete PES statements for each. -High sodium intake related to consumption of foods with high sodium content as evidenced by dietary recall, and high levels of cholesterol and sodium in labs. -Undesirable food choices related to disregard of low sodium diet and regular consumption of alcohol as evidenced by dietary recall and statement from patient. V. Nutrition Intervention39. 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?I would tell Mrs. Anderson that this is not the best idea. While she would lose weight on this diet, it would not be a healthy way to lose the weight (she would be losing water weight) and once she began eating normally again, she would gain the weight back (possibly more than she weighed before). I would stress to he that cutting CHO out of her diet is not the best idea, seeing as that is the body’s main energy source. I would encourage her to lose weight in a healthy way that does not restrict food groups. 40. When you ask Mrs. Anderson how much weight she would like to lose, she tells you she would like to weight 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?This is slightly unreasonable, due to the fact that her ideal body weight (according to her height, age and gender) is 149.1 lbs. 41. How quickly should Mrs. Anderson lose this weight?She should aim to be losing 1-2 lbs per week. 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). - Problem: high amounts of sodium in diet-goal: decrease BP-intervention: change diet to decrease amount of salt used in foods, use other herbs or spices to season-Problem: undesirable food choices-goal: decrease BMI to a normal weight range-intervention: drink less alcohol (switch to light beer when drinking) and eat more fruits and vegetables43. 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 in the butter, donuts, and 2% milk. Substitutions can be made with margarine, a bakery treat that is not deep fried (English muffin with low-sugar jam) and switching to skim milk.44. Assuming the foods in her 24-hour recall are typical of her eating pattern, outline necessary modifications you could use as a teaching tool.FoodsModification/AlternativeRationaleCoffee (3c/day)reduce to 1-2 cups; drink more waterbecome more hydrated, consume less caffeineOatmeal (w/margarine and sugar) or Frosted Mini-Wheatstop oatmeal with fresh fruit instead of margarine and sugar; try a new cereal (whole-grain cheerios)less sugar2% low-fat milkswitch to skim or 1%less fatOrange Juicelower sugar or fortifiedless sugar, more vitamins/mineralsGlazed DonutEnglish muffin with low sugar jamless sugar; less fatCanned tomato souplow sodium canned soupless sodiumSaltine crackerslow sodium pretzels or air popped popcornless sodiumDiet colawater (if diet soda still desired, reduce to a few times per week)more hydration12 bottle reg. beerlight beerless calories Baked chickencook without skin. don’t use salt, try other herbs and spices (or even lemon juice!)less sodium; less saturated fatBaked potato (w/1 tbsp butter, salt and pepper)use margarine instead of butter, don’t use saltless sodiumCarrots (glazed)plain raw carrots with hummus; plain cooked carrotsles sugar; lower saturated fatSalad with Ranch dressingswitch to lite or fat free Ranch dressinglower saturated fat; lower sodiumIce Creamfrozen yogurt; reduced sugar ice creamless sugar; less fat intake45. What would you want to reevaluate in 4 to 4 weeks at a follow-up appointment?I would want to re-evaluate her weight, and multiple aspects of her diet (how many fruits and vegetables are eaten, sodium intake, saturated fat intake). 46. Evaluate Mrs. Anderson’s labs at 6 months and then at 9 months. Have the biochemical goals been met with the current regimen?Some of Mrs. Anderson’s goals were met, her LDL cholesterol and Apop B were lowered, her HDL and Apop A were increased. Her sodium levels remained within normal limits, but there was not change. ................
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