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Lauren Hoover
KNH 411
September 8, 2016
Cardiovascular Case Study
I. Understanding the Disease and Pathophysiology
1. Define arterial blood pressure (BP) and explain how it is measured.
Arterial blood pressure can be defined as force exerted on by the blood on the
walls of the arteries during contraction and relaxation of the heart. Arterial blood
pressure is measured using a sphygmomanometer (Nelms, Sucher, Lacey, p294).
2. Discuss briefly the mechanisms that regulate arterial blood pressure
including the sympathetic nervous system, the renin-aniotensin-aldosterone
system (RAAS), and renal function.
Arterial pressure is determined partially by cardiac output, which is a function of
heart rate and stroke volume. Heart rate is determinate on the balance between the
parasympathetic and sympathetic nervous systems. The parasympathetic system
decreases heart rate, while the sympathetic system increases heart rate. The
sympathetic fibers stimulate the SA node and ventricles, which in turn release
norepinephrine to increase heart rate, increasing blood pressure. Sympathetic
activity also causes vasoconstriction and increased resistance of blood flow,
increasing blood pressure (Nelms, Sucher, Lacey, p295-296).
The renin-angiotensin-aldosterone system (RAAS) regulates the balance of fluids
and electrolytes which effects blood volume, which effect venous return, stroke
volume, and cardiac output. This is a main component of arterial blood pressure. A
hormone renin is released from the kidney to stimulate conversion to Angiotensin I,
which eventually gets converted to Angiotensin II. Increased levels of this will
stimulate Aldosterone production, causing kidneys to retain sodium, increasing
blood volume, which in turn increases blood pressure. Angiotensin II also stimulates
vasoconstriction, additionally causing an increase in blood pressure (Nelms, Sucher,
Lacey, p132).
The kidney is responsible for fluid and electrolyte balance, so if renal function is
low, changes in blood volume will occur, affecting cardiac output, and in turn,
lowering or raising blood pressure (Nelms, Sucher, Lacey, p295).
3. What is essential hypertension? What is the etiology?
Essential hypertension is also known as primary hypertension. Essential
hypertension is of unknown cause of which involves a complex interaction between
lifestyle choices and gene expression. Of individuals who have hypertension, 9095% of them have essential hypertension (Mahan, Escott-Stump, Raymond, p758).
4. What are the common symptoms of essential hypertension?
Often time hypertensive patients are asymptomatic. However, there are
some cardiac, cerebrovascular, and renal signs that can be observed as a result of
chronic hypertension. For example, left ventricular hypertrophy, stroke, absence of
pulse in extremities, microalbuminuria, etc. are all signs of a person with chronic
essential hypertension (Mahan, Escott-Stump, Raymond, p760).
5. Using the JNC 8 guidelines, how is the diagnosis of hypertension made?
What blood pressure readings are used to identify normal, stage 1
hypertension, and stage 2 hypertension?
Based on the JNC 8 guidelines, the diagnosis for stage 1 hypertension is made
when the systolic blood pressure is between 140-159 mm Hg for people ages 18-59,
and greater than or equal to 150 mm Hg for people older than 60 years old or when
diastolic blood pressure is between 90-99 mm Hg for all ages. The diagnosis for
stage 2 hypertension is made when the systolic blood pressure is above 160 mmHg
for people of all ages or when the diastolic blood pressure is greater than 100 mm
Hg for people of all ages (Nelms, Sucher, Lacey, p297).
6. List the risk factors for developing hypertension. What risk factors does
Mrs. Moore currently have? Discuss the contribution of ethnicity to
hypertension, especially for African Americans.
Risk factors for developing hypertension include individuals of black race,
male gender, youths, having a persistent diastolic pressure greater than 115 mm Hg,
smokers, individuals with diabetes mellitus, hypercholesterolemia, obese
individuals, individuals with excessive alcohol intake, and individuals with evidence
of end organ damage (Mahan, Escott-Stump, Raymond, p760). Currently, Mrs.
Moore’s risk factors include being of African American ethnicity, having a diastolic
blood pressure of 160 mm Hg, and being a previous smoker (Nelms, p38-39).
The prevalence of high blood pressure in African American is higher than
other races, at 43.0% for males and 45.7% for females (Nelms, Sucher, Lacey, p296).
Since many factors play a role in the development of hypertension, cultural, social
and/or biological components of African American individuals’ lives could be the
reason for this trend. Also, since they develop hypertension earlier in life and
maintain higher levels, their risk of fatal stroke, heart disease, and end-stage kidney
disease is also much higher (Mahan, Escott-Stump, Raymond, p759).
7. What are the four major modes of treatment for hypertension?
The four major modes of treatment for hypertension involves a
comprehensive plan involving weight reduction, physical activity, nutrition therapy,
and pharmacological interventions (Nelms, Sucher, Lacey, p298).
8. Dr. Evans indicated in his note that he will “rule out metabolic syndrome”.
What is metabolic syndrome?
There is no universally accepted definition for metabolic syndrome, and it is
a culmination of a variety of factors. Individuals with metabolic syndrome have at
least three or more of the following: waist circumference of more than 102 cm in
men and 88 cm in women, serum triglycerides of at least 150 mg/dL, HDL levels less
than 40 mg/dL in men and 50 mg/dL in women, blood pressure 135/85 mm Hg, or
fasting glucose of 100 mg/dL or higher (Mahan, Escott-Stump, Raymond, p471).
Metabolic syndrome is a combination of metabolic risk factors including abdominal
obesity, insulin resistance, dyslipidemia, hypertension, and prothrombotic state
(Nelms, Sucher, Lacey, p311).
9. What factors found in the medical and social history are pertinent for
determining Mrs. Moore’s coronary heart disease (CHD) risk category?
Factors that are important in determining Mrs. Moore’s CHD risk category
are her family medical history, of which her mother had chronic hypertension. Also,
age, of which she is in the risk range of older than 55. Her sex is something to
consider as well as her BMI. She is in the “overweight” category and not classified as
obese, so this is not necessarily a risk factor to consider. Her lipid profile should also
be considered. Her LDL level is elevated, and her HDL level is low, also contributing
to the risk. Her hypertension and previous cigarette smoking are also risk factors to
be considered (Nelms, Sucher, Lacey, p309-311).
10. How is hypertension related to other cardiovascular disorders? What are
the possible complications of uncontrolled hypertension?
Hypertension is the most prevalent contributory cause of cardiovascular
diseases and deaths. Chronic hypertension and when the hypertension goes
uncontrolled, many adverse diseases arise. Individuals can have coronary artery
disease, left ventricular hypertrophy, cardiac failure, cardiac enlargement,
myocardial infarction, cerebrovascular accident, aneurysm, impaired renal function,
retinal exudates and hemorrhages, and papilledema (Mahan, Escott-Stump,
Raymond, p760).
II. Understanding the Nutrition Therapy
11. Briefly describe the DASH eating plan and discuss the major nutrients
that are components of this nutrition therapy.
DASH stands for Dietary Approaches to Stop Hypertension and aims to not
only reduce sodium intake, but also to increase potassium, magnesium, calcium, and
fiber intakes within a moderate energy intake. With a daily intake of 2000 kcal, the
DASH diet would provide 4700 mg potassium, 500 mg magnesium, 1240 mg
calcium, 90 g protein, 30 g fiber, and 2400 mg sodium. The DASH diet stresses the
incorporation of grains, vegetables, fruits, low-fat dairies, lean meats, nuts and
seeds, and other foods into the diet (Nelms, Sucher, Lacey, p301-302).
12. Using the 2015 Dietary Guidelines, describe why decreased sodium intake
is targeted as a focus to improve the health of Americans.
The 2015 Dietary Guidelines list increased sodium intake as having an
association with increased risk in blood pressure and even an increased risk in
cardiovascular disease. Since hypertension is a precursor for a plethora of
detrimental conditions and diseases, sodium reduction definitely is a targeted focus
to improve American’s health (Mahan, Escott-Stump, Raymond, p763).
13. What do the current literature and Evidence Analysis Library (EAL)
indicate regarding the role of sodium intake in the control of hypertension? Is
there a significant correlation between sodium intake and cardiovascular
risk?
According to the EAL, seventeen studies have shown the benefit of reducing
sodium in the diet on lowering blood pressure. This correlation was given a Grade I,
meaning there is good supporting evidence
(http://andeal.org/topic.cfm?cat=2777&conclusion_statement_id=250636).
Current literature also supports lowering blood pressure by reducing sodium
intake. The Trials of Hypertension Prevention and several other randomized trials
have confirmed the positive effects of this dietary reduction (Mahan, Escott-Stump,
Raymond, p763).
14. What is the Mediterranean diet? How might this dietary approach be
appropriate for Mrs. Moore? Would this be culturally appropriate for her?
The Mediterranean diet emphasizes fruits, root vegetables, leafy green
vegetables, breads and cereals, fish, foods high in alpha linoleic acid, vegetable oil
products, and nuts and seeds. Red wine is also a key part of the Mediterranean diet,
containing resveratrol, appearing to lower blood pressure in some studies. At every
meal, this diet suggests fruits, vegetables, grains (mostly whole), olive oil, beans,
nuts, legumes and seeds, herbs and spices. Fish and seafood are to be eaten often,
and with poultry, eggs, cheese, and yogurt moderately. Meat and sweets are eaten
least often (Mahan, Escott-Stump, Raymond, p757).
Many studies have shown that the Mediterranean high fat diets are
associated with lower CHD incidence. Their main source of fat is olive oil, which
happens to be high in monounsaturated fatty acids, which can help lipoprotein
levels, a hypertension risk. Therefore, since Mrs. Moore has hypertension, this diet is
appropriate for her (Mahan, Escott-Stump, Raymond, p755).
This diet could be incorporated in some ways into her diet now. One thing
that Mrs. Moore could do is to season her foods with more herbs and spices, instead
of table salt. She could also try substituting the beer she drinks with red wine. She
could try to incorporate more fruits and vegetables as well as some
nuts/seeds/legumes. Since she is the one who goes shopping and cooks the meals,
she is in control of what she eats. She also does not have any food allergies or
aversions that would get in the way of maintaining this diet (Nelms, p39-40).
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 blood pressure.
Some lifestyle modifications that have been shown to reduce blood pressure
are reducing weight to maintain a normal body weight, adopt a DASH eating plain,
lower overall sodium intake, consuming no more than 2400 mg per day, possibly
more depending on level of hypertension, increase physical activity to at least 30
minutes a day most days a week, and limit alcohol consumption to no more than two
drinks per day for men and one drink per day for women (Nelms, Sucher, Lacey,
p304).
III. Nutrition Assessment
16. What are the health implications of Mrs. Moore’s body mass index (BMI)?
Mrs. Moore’s BMI is 25.8, which puts her at the lower end of the overweight
range (25.0-29.9). The health implications for being overweight are increased risk of
developing type 2 diabetes, sleep apnea, liver and gallbladder diseases, reproductive
disorders. osteoarthritis, and cancers of the endometrium, breast, prostate, and
colon. Overweight individuals also often suffer from psychosocial and emotional
consequences (Nelms, Sucher, Lacey, p260).
17. Calculate Mrs. Moore’s energy and protein requirements.
Height in meters: 66 inches = 1.676 m
Weight in kilograms: 160 lbs./2.2 = 72.727 kg
Protein requirement = 0.8g/kg body weight = 0.8g * 72.727 kg = 58.18 g protein
(Nelms, Sucher, Lacey, p66)
I chose to use the Estimated Energy Expenditure Equation for a Normal and
Overweight or Obese Woman 19 years and older (BMI greater than 18.5 ). For the
physical activity level, I chose to use 1.14, classified as low active. Mrs. Moore says
she walks 30 minutes 4-5 times a week, however she says sometimes she misses
these walks.
Estimated Energy Requirement = 387 – 7.31 x 57 + 1.14 x (10.9 x 72.727 + 660.7 x
1.676) = 2136.4 calories per day
(Mahan, Escott-Stump, Raymond, p28)
18. Identify the major sources of sodium and saturated fat in Mrs. Moore’s
diet. Compare her typical diet to the components of the DASH diet.
Major sources of sodium in Mrs. Moore’s diet include the Campbell’s tomato
soup, saltine crackers, popcorn, and added salt on her chicken and naked potato.
The major sources of saturated fat in her diet include the glazed donut, ranch
dressing, buttered popcorn, and added butter to her carrots and baked potato. She
also expressed how when she eats out, she will get either pizza or go to steakhouses,
both of which could be high in sodium and saturated fat (Nelms, 39-40).
Compared to the DASH diet, her diet lacks in fruits, while she seems to be
adequate in vegetables. She uses butter instead of the margarine or vegetable oil in
the DASH diet. Also, she doesn’t seem to get many nuts, seeds, or dry beans, which is
a component of the DASH diet. Her sweets choices are generally high in fat, like the
ice cream and glazed donut, which does not coincide with the DASH diet. And lastly,
her sodium intake is high, which is what is mainly limited in the DASH diet (Nelms,
Sucher, Lacey, p304).
19. What dietary assessment tools that target nutrients known to be
associated with hypertension and CVD risk might be useful in assessing Mrs.
Moore’s diet?
Some dietary assessment tools that could be useful include looking at
biochemical and medical tests, such as lipid profiles, albumin levels, electrolytes,
and glucose or HgbA1c values. In Mrs. Moore’s diet, it would be useful to obtain
glucose cholesterol, HDL, LDL, triglyceride levels from lab tests. Also, it would be
helpful to obtain information involving her food and nutrition-related history.
Assessing her pattern and frequency of her meals and snacks, her portion sizes, total
fat and cholesterol, saturated fats, types of carbohydrates, alcohol intake, sources of
sodium, frequency of restaurant meals, and physical activity would be very helpful
(Nelms, Sucher, Lacey, p302).
20. From the information gathered within the intake domain, list possible
nutrition problems using the diagnostic terms.
Possible nutrition problems include excessive energy intake, excessive fat
intake, inconsistent carbohydrate intake, inadequate fiber intake, and excessive
sodium intake (eNCPT).
21. Dr. Evans ordered the laboratory tests listed in the following table.
Complete the table with Mrs. Moore’s values from 6/25 and the potential
cause of any abnormalities.
Parameter
Normal Value
Pt’s Value
Glucose (mg/dL)
BUN (mg/dL)
70-99
6-20
101
20
Reason for
Abnormality
High sugar intake
High protein diet
or early signs of
kidney malfunction
(however,
technically no
abnormality –
within normal
Creatinine
(mg/dL)
0.6-1.1
0.9
Total cholesterol
(mg/dL)
HDL-cholesterol
(mg/dL)
<200
270
>59
30
LDL-cholesterol
(mg/dL)
<130
210
Apo A (mg/dL)
80-175
75
Apo B (mg/dL)
45-120
140
Triglycerides
35-135
(mg/dL)
Nelms, Sucher, Lacey, p309-310
150
range)
No abrnomality –
within normal
range
High SFA intake
Low MUFA/PUFA
intake, high SFA
intake
Low MUFA/PUFA
intake, high SFA
intake
Low HDL levels
due to low
MUFA/PUFA
intake, and high
SFA intake
High LDL levels,
due to low
MUFA/PUFA
intake, and high
SFA intake
Excess fat intake
22. Go to http://cvdrisk.nhlbi.nih.gov/. Using this online calculator,
determine Mrs. Moore’s risk of CVD based on her lipid profile. Are there other
factors that contribute to her CVD risk?
Mrs. Moore’s 10-year risk is 15.7%, compared to a 2.2% risk for individuals
with optimal risk factors. Her lifetime risk is 50%, compared to an 8% risk for
individuals with optimal risk factors. Other factors that contribute to her CVD are
her diet and exercise level, family medical history, past tobacco use, and others.
23. How do Mrs. Moore’s labs change between 6/25 and 3/15? What factors in
her history may have made an impact on these?
Between 6/25 and 3/15, some of Mrs. Moore’s lab levels improve. Her
glucose level drops to 96 mg/dL , which is in the normal range. Her cholesterol, and
her LDL levels decrease, not all the way to normal range, but maintain the
downward trend. Her HDL levels increase, also not to the normal range quite yet.
And lastly, her Apo A, Apo B and triglyceride levels improved to the normal ranges.
According to her health history, her weight loss and increased exercise
regimen have had an impact on the improvement of these levels. Also, the impact of
smoking cessation was very significant for Mrs. Moore (Nelms, 38-41).
24. Indicate the pharmacological differences among the antihypertensive
agents listed below.
Medications
Mechanism of Action
Diuretics
Decreases blood volume
by increasing urinary
output, inhibiting renal
sodium/water
reabsorption
Block beta or alpha
receptors in heart to
decrease heart rate and
cardiac output and
increase peripheral
vasodilation
Affect movement of
calcium, causing blood
vessels to relax, reducing
vasoconstriction
Beta-blockers
Calcium-channel
blockers
Nutritional Side Effects
and Contraindications
Hypokalemia,
hyperuricemia, anorexia,
N/V, diarrhea,
constipation. Avoid
natural licorice.
N/V, diarrhea, increases
weight, dry mouth, gas,
bloating, calcium may
interfere with absorption.
Edema, nausea, heartburn.
Contraindications: heart
failure. Avoid natural
licorice, limit caffeine,
avoid/limit alcohol.
ACE inhibitors
Angiotensin II receptor
blockers
Alpha-adrenergic
blockers
Vasodilate, decrease
peripheral vascular
resistance by interfering
with production of
angiotensin II and
inhibiting degradation of
bradykinin
Interfere with reninangiotensin system
without inhibiting
degradation of bradykinin
Block the vascular muscle
response to sympathetic
simulation and reduce
stroke volume
Hypotension, worsens
renal function,
hyperkalemia, dysgeusia,
cough. Contraindications:
pregnancy. Avoid natural
licorice and salt
substitutes.
Nausea. Avoid salt
substitutes, natural
licorice, caution with
grapefruit.
N/V, diarrhea,
constipation, mouth
dryness. Avoid natural
licorice.
Nelms, Sucher, Lacey, p300
25. What are the most common nutritional implications of taking
hydrochlorothiazide?
Hydrochlorothiazide inhibits the reabsorption of sodium, chloride, and
potassium. The nutritional implications of taking this medication is to maintain a
diet high in potassium and magnesium. Also to avoid eating natural licorice, which
may counteract the diuretic effect. Elecrolytes should also be monitored,
supplementation might be necessary, but calcium supplements should be used with
caution (Mahan, Escott-Stump, Raymond, p1103).
26. Mrs. Moore’s physician has decided to prescribe an ACE inhibitor and an
HMG-CoA reductase inhibitor (Zocor). What changes to Mrs. Moore’s labs
between 6/25 and 3/15, if any, would you attribute to Zocor use?
Mrs. Moore’s labs show an increase in BUN, which could be attribute to
taking the ACE inhibitor. Also, any increases in her potassium levels could be
attributed to taking the ACE inhibitor (Nelms, Sucher, Lacey, p300). The Zocor
would not have any effect on the changes between her labs (Mahan, Escott-Stump,
Raymond, p1103).
27. From the information gathered within the clinical domain, list possible
nutrition problems using the diagnostic terms.
Possible nutritional problems include overweight/obesity, limited adherence
to nutrition-related recommendations, and undesirable food choices (eNCPT).
IV. Nutrition Diagnosis
28. Select two nutrition problems and complete the PES statement for each.
PES Statement #1: Excessive sodium intake related to limited adherence to
nutrition-related recommendation of low-sodium diet as evidenced by 24-hour diet
recall and statement of non-compliance with diet guidelines.
PES Statement #2: Overweight related to undesirable food choices and
patterns, including high saturated fat intake as evidenced by 24-hour diet recall, and
HDL level of 38 mg/dL, LDL level of 147 mg/dL , and BMI of 25.8.
V. Nutrition Intervention
29. When you talk to Mrs. Moore on 3/15, you ask 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. Moore? How quickly should Mrs. Moore lose
this weight?
I would suggest a goal of a 5%-10% weight loss in the first six months. This
method has been shown to have the most lasting and consistent effects of
maintaining the weight loss, as well as being the most successful in reducing blood
pressure. I would explain this to Mrs. Moore and help give her some strategies and
ideas on how to lose weight in this time frame. I would explain that rapid, extreme
weight loss initially, is not sustainable and does not necessarily translate to longterm weight loss maintenance. Ideally, Mrs. Moore would lose no more than 1-2
pounds per week (Nelms, Sucher, Lacey, p272-278).
30. 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).
PES Statement #1: Excessive sodium intake related to limited adherence to
nutrition-related recommendation of low-sodium diet as evidenced by 24-hour diet
recall and statement of non-compliance with diet guidelines.

Ideal Goal: Reduce sodium levels to 2400mg per day.

Intervention: Incorporate DASH diet on food choices and patterns
and counsel on different ways to incorporate low-sodium food items
into the diet and alternate salt options.
PES Statement #2: Overweight related to undesirable food choices and
patterns, including high saturated fat intake as evidenced by 24-hour diet recall, and
HDL level of 38 mg/dL, LDL level of 147 mg/dL , and BMI of 25.8.

Ideal Goal: Increase HDL levels to 45 mg/dL or above, decrease LDL
level to 129 mg/dL or lower, and decrease BMI to under 25.

Intervention: Nutrition counseling on importance of reducing foods
high in saturated fat and collaborate with patient to come up with
ways to cater menu to foods patient likes, while maintaining DASH
guidelines.
31. List your major recommendations for dietary substitutions and/or other
changes that would help Mrs. Moore reach her medical nutrition therapy
goals, to be consistent with the DASH diet and sodium intake guidelines.
To help Mrs. Moore reduce her sodium levels I would recommend her to
avoid fast-food restaurants, request foods at restaurants to be prepared without
added salt, MSG, or any other salt-containing ingredients, avoid foods that are
pickles, cured, or any soy sauce or broth, avoid adding salt to foods at the table, limit
excessive condiments, and choose fruits and vegetables for snacks instead of salty
foods, like saltines and popcorn. I would also recommend that she substitute spices
and herbs for salt when cooking to maintain flavor and quality of the meal.
To help Mrs. Moore lose weight in conjunction with the DASH plan, I would
recommend that she increase her fruit and vegetable consumption, especially at
breakfast and lunch, and increase low-fat dairy products. I would also recommend
that she use fat-free condiments, less margarine/butter, eat smaller portions, and
limit foods with excessive added sugar.
(Nelms, Sucher, Lacey, p305-306).
32. Your appointment with Mrs. Moore on 3/15 is concluded. What would you
want to reevaluate at her next follow-up appointment.
I would want to assess a new lipid profile to see if her HDL and LDL levels
improved. I would also want to hear about her diet, so I would suggest for her to
bring in a three-day diet food recall. This way I could see if she was adhering to the
DASH diet guidelines.
I would also want to look at her anthropometric measurements to see if she
was losing weight and to look at any changes in her BMI. I would also want to see if
her blood pressure was improving from her dietary modifications. These
assessments would be helpful in monitoring the effectiveness and adherence of the
recommended dietary changes.
(Nelms, Sucher, Lacey, p322)
References
International Dietetic & Nutrition Terminology (IDNT): Reference
Manual. Standardized Language for Nutrition Care Process. Academy of
Nutrition and Dietetics, 2014. Retrieved from ncpt.webauthor.com
Mahan, L.K., Escott-Stump, S., Raymond, J.L. Krause’s Food Nutrition & Diet Therapy,
13th ed. Philadelphia, PA: W.B. Saunders Company, 2012
Nelms M. Medical Nutrition Therapy A Case Study Approach 5th ed., Cengage
Learning, 2017.
Nelms M. Sucher K, Lacey, K. Nutrition Therapy and Pathophysiology. 3rd ed.
Cengage Learning, 2016.