Case 4: Hypertension and Cardiovascular Disease

Jazzmin Hardaway
Jessica Manner
Sydney Maxfield
Tina Nguyen
Ezekiel Nwaigwe

NUTR 484: Medical Nutrition Therapy

San Francisco State University
October 23, 2019
CASE 4: Hypertension and Cardiovascular Disease

I. Understanding the Disease and Pathophysiology

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.
The risk factors for developing HTN include excessive sodium intake, low potassium,
physical inactivity, cigarette smoking, excessive alcohol, stress, family history, ethnicity(person
of color), gender (males), diabetes mellitus, BMI >30, and ​hypercholesterolemia.
Mrs.Moore’s risks factors are her family history, prior smoker of 2 packs per day, drinking 2
alcohol drinks in a day, excessive sodium intake, and ethnicity

II. Understanding Nutrition Therapy

11. Briefly describe the DASH eating plan and discuss the major nutrients that are components
of this nutrition therapy.
DASH is an acronym for Dietary Approach to Stop Hypertension. It is a multifaceted plan used
in nutrition therapy and lifestyle change that reduces blood pressure through a 2000 kcal diet that
focuses on reducing sodium intake, limiting alcoholic beverages, and increasing potassium,
magnesium, calcium, and fiber. The daily servings of the diet are: 7-8 for grains and grain
products as this food group will provide the majority of energy and fiber; 4 - 5 servings of
vegetables for their density in potassium, magnesium, and fiber; 4 - 5 for fruit for the same
reasons as vegetables; 2 - 3 low fat or fat free dairy for protein and calcium; 2 or less servings of
meats, poultry, and fish for protein and magnesium; 4 - 5 for nuts, seeds, and dry beans because
they are high sources of energy abundant with magnesium, potassium, protein, and fiber; 2 - 3
servings of fat and oil which account for 27% of calories; and lastly, sweets are limited to 5
servings a week and are recommended to be low fat (Nelms et al., 2016, p. 296).

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.
Lifestyle modifications that will reduce blood pressure are weight loss and increasing physical
activity. Weight loss can be achieved through increased physical activity and/or an energy
restricted diet. Increased physical activity benefits reduces LDL cholesterol levels and increasing
HDL cholesterol levels - alleviating risk factors associated with cardiovascular risk (Nelms et al.,
2016, p. 267). Smoking cessation is also an important lifestyle change. Sodium restriction in diet
as well as increased intake of potassium, calcium, and magnesium - such as seen when
implementing the DASH diet - has shown to be effective in reducing blood pressure (Nelms et
al., 2016, p. 295). Limit of alcohol consumption will also alleviate hypertension. As
CASE 4: Hypertension and Cardiovascular Disease

recommended by the U.S Dietary Guidelines and JNC7, men should limit to a daily max of two
drinks while women should limit to a max of one drink. A drink is defined as follows: 12 oz.
beer, 5 oz. wine, or 1.5 oz. spirit. Smoking cessation is a very important change in lowering risk
of hypertension and heart disease (Nelms et al., 2016, p. 297).

III. Nutrition Assessment

16. What are the health implications of Mrs. Moore’s body mass index (BMI)?
Her BMI is 25.8 - placing her in the overweight category (25.0 - 29.9). Health implications
associated with this category include risk of: hypertension, high blood pressure, hyperglycemia,
hyperinsulinemia, hyperlipidemia, lipid abnormalities such as: elevated total and LDL
cholesterol and triglyceride serum levels; lower HDL serum level - which are risk factors
associated with coronary heart disease, diabetes mellitus type 2, hepatobiliary complications,
high prevalence of asthma, heart disease, arthritis increased risk of incontinence, and and certain
cancers which include: endometrial, colon, gallbladder, prostate, kidney, and postmenopausal
breast cancer (Nelms et al., 2016, p. 255 - 256).

The psychosocial or emotional consequences that stem from the social determinants that
glamorize an ideal body shape as well as social discrimination based on fat-shaming may induce
poor mental health such as guilt, depression, anxiety, and low self-worth (Nelms et al., 2016, p.
253)

17. Calculate Mrs. Moore’s energy and protein requirements.

MSJ: (10x72.7) + (6.25x167.6) - (5x 57) - 161= 1,328.5 calories
Activity level: 1.2-1.3
1,328.5x1.2= 1,594.2 calories
1,328.5x1.3=1,727.05 calories
Mrs. Moore’s range for energy is 1,594 - 1,727 calories
Protein Requirements:
25.8 BMI (overweight)
0.8g PRO per kg of wt
= 0.8g*72.7kg = 58 g of protein/day

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.
CASE 4: Hypertension and Cardiovascular Disease

Mrs. Moore is getting most of her sodium intake from her canned tomato soup and saltine
crackers that she has for lunch and adding to her intake with the salt she uses for her chicken and
a baked potato for dinner. The AHA recommends a maximum of 2,300mg and to ideally aim for
closer to 1,500mg per day. Mrs. More is already close to 1,200mg at lunchtime alone. This does
not include the additional salt she is using for her chicken and a potato for dinner nor does it
include the amount of sodium in her buttered popcorn that she is having for snack. One teaspoon
of salt contains 2,325mg of sodium so she is most likely using over this amount.
For dinner she gets most of her saturated fat intake from butter she uses to cook her carrots, top
her potato, and cover her popcorn in. She is most likely also consuming a heavy dose of
saturated fat from the donut she has for breakfast.
Mrs. Moore’s Diet is not currently in line with components of the DASH diet as it does not
emphasize whole grains or fruits, nor does it reduce alcohol or sweets. Her source of whole
grains from her recall looks to only be from the popcorn that she is consuming with butter. Mrs.
Moore’s only fruit intake was only in the orange juice she consumed and therefore was not able
to benefit from the fiber content of the oranges. Her vegetable intake should be adjusted as it is
paired with saturated fats from butter and excess ranch-style dressing.
Women following a DASH diet should also limit their alcohol intake, Mrs. Moore should
consider reducing her usual two alcoholic drinks to one.
Although Mrs. Moore is doing a great job at drinking her coffee black and not adding any sugar
or cream to it, she still should consider reducing her sugar intake by sweetening her oatmeal with
berries or a banana instead of sugar and replacing her glazed donut with a whole grain toast with
a nut butter and fruit.

20. From the information gathered within the intake domain, list possible nutrition problems
using the diagnostic terms.
- Excess sodium intake
- Excess saturated fat intake
- Inadequate fiber intake
- Excess alcohol intake
- Excess caffeine intake
- Excess fat intake

IV. Nutrition Diagnosis

28. Select two nutrition problems and complete the PES statement for each.
CASE 4: Hypertension and Cardiovascular Disease

1. Excess sodium intake related to high sodium food consumption in 24-hour recall as
evidenced by stage 2 hypertension.
2. Excess fat intake related to unchanged dietary intake as evidenced by serum cholesterol
level of 270 mg/dL, and patient report of high-fat foods including a donut, buttered baked
potato, buttered popcorn, and ranch dressing.
V. Nutrition Intervention
29. When you talk with Mrs. Moore on 3/15, you ask 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. Moore? How quickly
should Mrs. Moore lose this weight?
Although this goal may be attainable, it is not necessary for a woman of her age to undergo
strenuous dietary restrictions for such drastic weight loss goals. As her dietitian, I would be more
focused on motivating her to adjust her diet than to lose a certain amount of weight right away.
The weight loss will be a symptom of her necessary dietary adjustments. If she is very set and
motivated to have a weight loss goal in mind after a dietary consultation on how to reduce her
saturated fat and sodium intake, I would suggest she lose 10-12lbs (7.5%) over the next three
months as this will take her out of the overweight category of BMI and is an attainable and
reasonable goal that can be achieved by necessary dietary alterations.

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 the etiology).
1. One goal would be for Mrs. Moore to reduce the amount of saltines she consumes from
10 packets for lunch, to 5 packets, for a week.
2. The second goal would be for her to cut the amount of butter she uses in half for each
meal, for a week.
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.
Mrs. Moore’s recommendations according to the DASH diet would be to increase fiber,
potassium, magnesium, calcium, decreasing sodium intake, and lower consumption of saturated
fat with an emphasis on vegetables, fruits, low fat/non-fat dairy, whole grains, fish, poultry, and
nuts. She is familiar with the recommendations for decreasing sodium intake from a pamphlet
when first diagnosed with hypertension. Mrs. Moore and her husband complied with the
recommendations at first but no longer comply with them because the food was bland and
tasteless. One recommendation would be to inform her to gradually use less salt over time, as her
taste buds will adjust to the amount of sodium used. Gradually tapering off the amount of salt
CASE 4: Hypertension and Cardiovascular Disease

will help to avoid food tasting bland. Recommendations for lowering sodium intake from Mrs.
Moore’s 24 food recall would be buying low sodium tomato soup or making homemade batches
ahead of time and freeze them, and purchasing low sodium crackers or substituting crackers with
whole grain bread. Using less/eliminating added sodium to her overall cooking, for example,
removing added salt to her baked chicken, and baked potato. Substituting flavor-enhancing
techniques such as Mr. Dash, using lemon, vinegar, and herbs. She could also substitute the use
of saturated fats such as butter for unsaturated fats such as olive oil. An example of this would be
substituting eating buttered popcorn for olive oil popcorn, and glazing her carrots with olive oil
or another unsaturated oil instead of using butter. For the salad, it would be recommended to
substitute ranch for olive oil and vinegar. Fruits are of high importance for the DASH diet and
the 1 c of orange juice should be substituted with an orange. Alcohol recommendations for
women are 1 day, and for dinner 1 beer should be consumed instead of 2.

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 ask Mrs. Moore to bring in a food diary from the past week and to get her blood work
re-done so we could evaluate her progress. I would also reevaluate her blood pressure, weight
and ask how she is adjusting to dietary changes.

Additional Questions: ​as it pertains to this patient in the case study.

*What other healthcare professionals may be involved in this patient’s care? What are their
roles? Consider both inpatient and outpatient encounters.
Cardiologist - examining the patient’s risk of MI
Psychologist - talk with the patient about their feeling towards a low sodium diet.
Nurse - checking BP and reading blood levels
Pheblomistis- draw blood
lab tech - run a blood test
Family Practioner- doing physicals and monitoring the patient’s health over time.

*Discuss in 5 sentences or less, the impact of healthcare policy and different healthcare delivery
systems on this patient’s care.

Considering that the Moores find it difficult to maintain a low-sodium diet, and that Mrs. Moore
has stage 2 HTN, heart disease, and early COPD, she should receive free nutrition counseling to
help manage her illnesses. The Preventive Health Services Act, along with the Affordable Care
Act (ACA), states that insurance companies and some employers must provide nutrition
CASE 4: Hypertension and Cardiovascular Disease

counseling for overweight and obese Americans with at least one cardiovascular risk factor free
of charge. Mrs. Moore should receive counseling to help her find salt-alternatives for flavoring
her food, reduce her saturated fat intake, reduce her alcohol consumption, and develop overall
healthier eating habits.
CASE 4: Hypertension and Cardiovascular Disease

Reference

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