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.

Blood Pressure mm HgCategory Systolic BP Diastolic BPNormal < 120 And < 80Prehypertension 120-139 Or 80-89Hypertension Stage 1 140-159 Or 90-99Hypertension Stage 2 > 160 Or > 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 Potassium

(minimum

4,700 mg/

120 mEq)

Sodium

(maximum

2,400 mg/

100 mEq)

Magnesium

(500 mg)

Calcium

(minimum

1,240 mg)

Total

Fat

(g)

Saturated

Fat (g)

Cholesterol

(mg)

Fiber

(g)

Oatmeal with

margarine and

sugar

184.8 mg 286.3 mg 59.6 mg 163.6 mg 2.8 g 0.5 g 0 4.3 g

Coffee 252.5 mg 11.4 mg 17.5 mg 12.1 mg .086

g

.01 g 0 0

Glazed donut 45.9 mg 180.9 mg 7.7 mg 27.0 mg 10.3

g

2.7 g 14.4 mg 0.67

g

Tomato Bisque

soup

1467.7

mg

2691.8

mg

60.9 mg 450.7 mg 16.0

g

7.6 g 54.8 mg 1.2 g

Saltine crackers 46.2 mg 321.6 mg 0.2 mg 20.4 mg 3.4 g 0.5 g 0 0.9 g

Baked Chicken 413.4 mg 668.9 mg 45.6 mg 24.0 mg 13.1

g

3.7 g 141.7 mg 0

Baked Potato 610 mg 376 mg 39.0 mg 7.8 mg 0.16

g

0.4 g 0 2.3 g

Salad 272.4 mg 466.3 mg 0.4 mg 57.1 mg 23.58

g

3.63 g 12.2 mg 1.13

g

Butter Pecan

Ice Cream

0 446.1 mg 0 353.6 mg 28.0

g

11.4 g 49.0 mg 2.4 g

Regular Beer 118.0 mg 10.7 mg 25.0 mg 14.3 mg 0 0 0 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 Normal Value Patient’s

Value

Reason for

Abnormality

Nutrition Implication

Glucose 70-110 mg/dL 92 Diabetes 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

Urea Nitrogen

High levels of BUN can

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 High If the total cholesterol

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)

mg/dL

> 45 (men) mg/dL

30 Low HDL or

hypoalphalipo-

proteinemia

Low HDL is

problematic, because

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 101-199 (women)

mg/dL

94-178 (men)

mg/dL

75 Low Apo A This can lead to

cardiovascular disease

and build up of plasma

concentration

Apo B 60-126 (women)

mg/dL

63-133 (men)

mg/dL

140 High Apo B This can lead to higher

LDL levels and

therefore increasing

chances of CAD, CVD,

and high blood

pressure

Triglycerides 35-135 (women)

40-160 (men)

150 High

Triglycerides

This can raise your risk

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

by increasing urinary

output, inhibit renal

sodium and water

reabsorption

Increase in potassium

supplements, dry mouth pg

291

Beta-blockers Blocks B-receptors in

heart to decrease heart

rate and cardiac output

These lead to nausea,

diarrhea, calcium may

interfere with absorption,

upset stomach, dry mouth,

stomach pain, gas or

bloating, and heartburn

Calcium-channel blockers Affect the movement in

calcium, cause blood

vessels to relax, therefore

reduce vasoconstriction

Leads to edema, nausea,

heartburn, heart failure or

greater than first degree

heart block, avoid natural

licorice, limit caffeine, and

avoid or limit alcohol

ACE inhibitors Vasodilators that reduce

BP by decreasing

peripheral vascular

resistance by interfering

with the production of

angiotensin II from

angiotensin I and

inhibiting degradation of

bradykinin

Hypotension especially in

elderly patients, can worsen

renal function,

hyperkalemia, dysgeusia,

causes dry, nonproductive

cough, and salt substitutions

should be avoided

Angiotensin II receptor blockers Interferes with rennin-

angiotensin system

without inhibiting

degradation of

bradykinin

May increase serum

potassium, increase nausea,

dysgeuisa, and salt

substitutes should be

avoided

Alpha-adrenergic blockers Blocks the vascular

muscle response to

sympathetic stimulation;

reduces stroke volume

Nausea, vomiting, diarrhea,

and mouth dryness are all

common side effects and

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

down to one or two cups of

coffee a day

Coffee does not satisfy

thirst, where as water

satisfies thirst and

improves the body

quality and brain

function

Oatmeal (w/margarine &

sugar) or Frosted Mini-Wheats

Decrease the amount of sugar

and margarine that is used, use

a spray butter instead

Decrease the amount of

lipid being consumed as

well as the amount of

sugar to help with

weight loss

2% low fat milk Change to 1% milk or even

skim if possible

Lessen the amount of

lipid consumed

Orange juice Get the calcium fortified

orange juice

Increase in calcium in

the diet, especially for

an aging woman

Glazed donut Cake donut if a donut is

needed, or whole wheat toast

with peanut butter or a piece

of fruit for sweetness

A plain cake donut

would be less fat, whole

wheat toast would be

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 Make the soup with water or

1%/skim milk instead

Decrease the lipid

content

Saltine crackers 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 If alcohol is needed, then drink

light beer

Lessen the amount of

calories consumed

Baked chicken 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,

salt & pepper)

Use spray butter instead and

only use pepper

Decrease lipid and

sodium intake

Carrots Cut out the glazing and

sprinkle with pepper or

cayenne pepper for a kick

Decrease the lipid and

sodium intake

Salad w/ranch style dressing Use a light/fat-free ranch

dressing instead

Decrease the lipid

intake

Ice Cream 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.