MNT II: INTRODUCTION
• NCP – Nutrition screening to know if the patient is at-risk
or already malnourished.
o % Weight loss as basis of malnourished
• ADIME is a cycle
• Nutrition Screening/Referral
o Malnutrition Universal Screening Tool (MUST) -
reliability & sensitivity
▪ A five-step screening tool to identify
adults who are malnourished, at-risk, or
obese.
▪ How to ask if the patient lose weight? – If
their belt/clothes are loose.
▪ Acromion to olecranon process for MUAC
o Pediatric Nutrition Screening Tool (PNST)
▪ Consists of 4 simple yes/no questions
(weight loss, poor weight gain, decreased
intake, visibly under/overweight) whereby
2 affirmative responses are used as a
predictor of nutrition risk
▪ More subjective
o Pediatric Yorkhill Malnutrition Score (PYMS)
▪ Designed to detect children at risk of
energy/protein under-nutrition
(malnutrition) only, not children with
vitamin and/or mineral deficiencies or at
risk of over-nutrition.
• Assessment
o Body composition; hand grip strength to test
protein nutrition
o Anthropometric, Biochemical, Clinical, Dietary
o Muscle & fat wasting
• Diagnosis – Find priority problem
o Intake
o Clinical (PES)
o Behavioral/Environmental
• Intervention
o Food & nutrient delivery
o Nutrition Education – teaching
o Nutrition Counseling – Personal
o Coordination of Nutrition Care
• Monitoring & Evaluation
o Outcomes
o If there are any changes to the patient
• Follow-ups & Recommendations
MNT II: CARDIOVASCULAR
• Leading cause of death
• Coronary Heart Disease is the most prevalent,
followed by stroke.
• Occurs in person 65 years and older
• 1/3 occurred prematurely
• 1st affects blood vessels
• Normal Heartbeat - 60 to 100 beats per minute
• Arrhythmia – Irregular heartbeat; it stops & then
starts again
• Coronary Heart Disease is a form of CVD, its
underlying cause is atherosclerosis which causes MI
and angina, strokes, and peripheral circulation
(intermittent claudication & gangrene)
• Atherosclerosis
o Process begins in childhood & takes decades
to advance
o Pathogenesis is multifactorial
o Lesions are results of:
▪ Proliferation of smooth-muscle cells,
macrophages, & lymphocytes (cells
involved in inflammatory response).
▪ Formation of smooth-muscle cells into
a connective tissue matrix.
▪ Accumulation of lipid & cholesterol
(cellular waste products, calcium,
fibrin) around cells or intimal layer
(plaque/atheroma).
▪ Plaque forms in response to injuries to
endothelium wall.
o Is an inflammatory & proliferative response to
arterial wall injuries.
o Atherogenesis allows lipoproteins to
accumulate in intima
o Phases of atherogenesis
▪ Phase I – asymptomatic phase
▪ Phase II – plaque w/high lipid content
that may be prone to rupture
▪ Phase III – Acute, complicated lesions
w/rupture & nonocclusive thrombus
▪ Phase IV - Acute, complicated lesions
w/rupture & occlusive thrombus;
Associated with MI, angina, or sudden
death
▪ Phase V – Fibrotic/occlusive lesions
w/similar clinical outcomes.
o Thrombosis – Result of rupture of fibrous
plaque cap
 ▪ Aspirin is commonly used prevention
• Blood Lipids are transported in blood bound to
proteins, which are called lipoproteins
o Five classes of lipoproteins:
▪ Chylomicrons – transport dietary fat &
cholesterol from small intestine to
liver & periphery; Once in
bloodstream, it hydrolyzes by
lipoprotein lipase and when 90% of it
is hydrolyzed it is released back to
bloodstream.
▪ Very low-density lipoprotein –
synthesized in liver to transport
endogenous triglycerides &
cholesterol; 60% of it is triglycerides
▪ Intermediate density lipoprotein –
formed with catabolism of VLDL &
precursor of LDL
▪ Low density lipoprotein – primary
cholesterol carrier in blood
▪ High density lipoprotein – Contains
more protein
HYPERTENSION
• NUTRITIONAL ACUITY RANKING – Level 3 (Moderate
Role)
• Sustained SBP and DBP ≥ 140/90 mmHg
• Not a disease entity in itself, but a symptom due to
increased cardiac output and increased resistance of
blood vessel walls to blood flow.
• 22.3% of adults are hypertensive
• Peaks at 50-59 years of age
• Males have prevalence in every age group
• Risk Factors
o Modifiable – Can be altered
▪ Medical condition
▪ Dietary Habits & Practices
▪ Lifestyle Practices (smoking and
alcohol)
▪ Health & Medical Condition (Obesity
BMI>30; DM2, cholesterol levels)
▪ Stress & Anxiety
▪ Sleep
o Non-Modifiable – Cannot be altered
▪ Age
▪ Genes
▪ Sex/gender
▪ Family history of disease
▪ Race
• Sign – Manifestation of disease that physicians
perceive.
• Symptoms – Apparent to the patient itself
(nararamdaman)
• Signs & symptoms of Hypertension:
o Usually asymptomatic
o Elevated BP
o Severe headaches
o Chest pain
o Dizziness
o Nausea
o Vomiting
o Blurred Vision / Change in vision
o Confusion
o Buzzing in the ears
o Nose bleeds
o Abnormal Heart Rhythm
o Difficulty Breathing
• Types
o Essential Hypertension (Primary) - about 90%
of cases, specific cause is not known; certain
factors are recognized as contributing to high
blood
o Secondary Hypertension - in about 10% of the
case is caused by another disease. Treatment
targets the root cause (i.e., CKD, sleep apnea,
tumors or diseases of the adrenal, coarctation
of aorta, pregnancy, use of BC pills, alcohol
addiction, thyroid dysfunction)
o Renal Hypertension (aka renovascular
hypertension) – caused by narrowing in the
arteries that deliver blood to the kidney. Can
cause CKD; usually asymptomatic unless the
BP is dangerously high.
▪ Symptoms include: headache,
confusion, blurry or double vision,
bloody-pink urine, nose bleeding.
• Etiology (Root Cause) - Renin-Angiotensin-Aldosterone
System (RAAS), system that regulates fluid-electrolyte
balance and systemic blood pressure.
o Renin - an enzyme that helps control your
blood pressure and maintain healthy levels of
sodium and potassium in your body
o Angiotensinogen - a component of the renin-
angiotensin system (RAS), a hormone system
that regulates blood pressure and fluid
balance
o Angiotensin - a hormone that helps regulate
your blood pressure by constricting
(narrowing) blood vessels and triggering water
and salt (sodium) intake
o Aldosterone - a hormone that helps regulate
your blood pressure by managing the levels of
sodium (salt) and potassium in your blood and
impacting blood volume.
o Liver produces plasma protein
o Kidneys sense BP or  BV sensed by JGA
o Posterior pituitary gland release diuretic
hormone (ADH)/vasopressin H2O
reabsorption;  BV
o Constricts blood vessels (arterioles);
peripheral resistance
o Stimulates adrenal cortex to release
aldosterone ( Na+ reabsorption in kidney
and  BV)
• Primary Prevention:
o Dietary Modification
▪ Emphasis on fruits and vegetable
intake & low-fat dairy intake
▪ Reducing fat intake (saturated fats,
cholesterol and trans fatty acids)
▪ Reducing intake of dietary sodium &
 intake of increase intake foods and
other supplemental foods rich in
vitamins/minerals, especially
• Calcium and Vitamin D
• Magnesium
• Potassium
o Weight Reduction
▪ Attain ideal BMI
▪ Reduce waist circumference and
achieve optimal waist-to-hip (WHR)
ratio
o Changing Lifestyle
▪ Increasing physical activity
▪ Stopping smoking
▪ Limit alcohol consumption
▪ Stress Management
• Pharmacologic intervention – Blood-pressure lowering
drugs / Antihypertensive Drugs:
o Beta blockers: Reducing the heart rate thus 
the blood pressure.
o Diuretics: urination that reduces sodium &
fluid content resulting in  blood pressure.
o Angiotensin-converting enzyme (ACE)
inhibitors: Widens blood vessels that aids in
easy blood flow and  the blood pressure.
o Angiotensin II receptor blockers (ARBs): Helps
relax the blood vessels to lower the pressure.
o Calcium channel blockers:  amount of
calcium entering heart muscles thereby  the
heart rate & controlling blood pressure.
o Alpha (∝) blockers: Muscles of arteries &
veins are relaxed thus  the blood pressure.
o Renin inhibitors: Inhibits the enzyme that
favors the production of angiotensin (a
peptide hormone, which aids in regulation of
blood pressure) which constricts blood
vessels.
• Potential Side Effects of Common HTN Drugs
DRUG INTERACTION SIDE EFFECTS
Diuretics Spironolactone is potassium- Diarrhea
sparing GI Bleeding
Thiazides (furosemide) deplete
calcium and require
supplementation
ACE Enalapril, Accupril and Lotensin Nausea, abdominal
prevent A-I from conversion; pain
useful in CHF
Should be taken 1
hour before meals
Beta Atenolol, Propranolol decreases Dizziness
Blockers the force and rate of the heart Nausea
contractions, thereby decreasing
BP
ARBs Block the action of a hormone that Dizziness
causes BP to narrow. ARBs work as Leg swelling (for
well as ACE inhibitors, but less those with renal
likely to cause the cough artery problems)
associated with ACE inhibitors
• Nutrition Management
o Note: Types of hypertensions based on their
sensitivity and reaction to salt/sodium:
▪ Salt-sensitive hypertension refers to
individuals with hypertension show a
greater decrease in their blood
pressures in response to reduced
sodium intake than others
▪ Salt-resistant hypertension refers to
individuals with hypertension whose
blood pressures do not change
significantly with lowered salt intakes.
DIETARY INTERVENTION:
o Dietary Approaches to Stop Hypertension
(DASH) Diet - designed to help treat or
prevent high blood pressure (hypertension)
▪ includes foods that are rich in
potassium, calcium and magnesium
▪ limits foods that are high in sodium,
saturated fat and added sugars.
o Salt-reduction - According to the 2018
ACC/AHA,
▪ Sodium guideline for most adults to
aim for at least 1000 mg/day
reduction in sodium
▪ For adults with elevated blood
pressure to reduce sodium to an
optimal goal of 1500 mg/day
▪ For those with normal blood pressure,
an intake of less than 2300 mg of
sodium, the equivalent of 6 g of salt,
each day
o Fats and Lipids - Omega-3 fatty acids are not
highlighted in blood pressure treatment
guidelines, although intakes of fish oils
exceeding 2 g/day may have blood pressure
benefits.
o Alcohol - Should be limited to no more than
two drinks daily in men, which is equivalent to
2 oz of 80-proof whiskey, 10 oz of wine, or 24
oz of beer. Women or lighter-weight men
should consume half this amount. Excessive
alcohol consumption is associated with left
ventricular function.
NUTRITION EDUCATION, COUNSELING, CARE
MANAGEMENT:
o Exercise -  amount of aerobic or dynamic
resistance physical activity to a minimum of 90
to 150 minutes per week is recommended as
an adjunct therapy in hypertension
management. or substantial health benefits,
the dietary guidelines recommends at least
150 minutes a week of moderate-intensity
physical activity as well as muscle-
strengthening activities that include all major
muscle groups
o Use of Herbs and Spices as alternatives to
salt - Discuss other flavoring & seasonings and
how to incorporate them into recipes
o Stress Management - Assess psychological &
psychosocial factors leading to HPN. Chronic
stress can cause repeated blood pressure
elevations as well as by stimulation of the
nervous system to produce large amounts of
vasoconstricting hormones that increase
blood pressure.
o Adequate sleep - lack of sleep could cause
swings in hormones. Hormone changes can
lead to high blood pressure and other risk
factors for heart disease
o Weight reduction - obesity leads to
proinflammatory and prothrombotic state that
potentiates HPN
o Omit or reduce alcohol - alcohol can affect
the muscles in your blood vessels and can
cause them to become narrower.
o Reduce Sugar-Sweetened Beverages - high
intake of simple carbohydrate is associated
with increase in BP
• Role of Selected Dietary Factors in HPN
o Sodium - mostly found in extracellular fluids,
but may cross cell walls into the intracellular
fluids, thus causing edema. Edema of the
blood vessels increases resistance to blood
flow, causing BP to rise.
o Potassium - helps lower BP in individuals with
low serum potassium, deficiency may occur
when diuretics (i.e., chlorothiazide) are used,
hence supplementation is necessary
o Magnesium - reduces intracellular sodium,
hence helps lower BP
o Calcium - results of studies on Ca
supplementation have been conflicting, some
report beneficial effects on BP, others non-
significant effects.
o Cadmium - may be implicated in etiology of
HTN. High concentration of renal Cadmium
has been found in hypertensives
o N-3 polyunsaturated fats (in fish oils) -
promote synthesis of prostaglandin which
helps regulate sodium and potassium
excretion
o Alcohol - high intakes (>3 drinks/day) can
cause vasoconstriction, hence raise BP.
Moderate drinking is acceptable:
▪ Men: 40g (2 drinks/day)
 ▪ Women: 20g (1 drink/day) o Chylomicrons
▪ Transport dietary fat & cholesterol
from small intestine to liver &
periphery
▪ Synthesized in the intestines
▪ Consist mostly of TGs absorbed from
the diet
o Pre-β Lipoprotein (VLDL)
▪ Synthesized in liver
▪ Transport endogenous triglycerides &
cholesterol
▪ Consist largely of TGs (60%) but also
contain some cholesterol
o β Lipoprotein (LDL)
▪ Primary cholesterol carrier (2/3) in
blood
▪ Implicated in atheroma formation
(“bad” cholesterol)
o 𝛂 Lipoprotein (HDL)
▪ Contains more protein
▪ Prevent plaque formation (“good”
cholesterol)

HYPERLIPIDEMIA
• Nutritional Acuity Ranking - Level 3 (Moderate Role)
• Elevation of plasma lipids, including cholesterol,
cholesterol esters, phospholipids & triglycerides
o Hyperlipoproteinemia – Elevated plasma
lipoproteins
• Classes of Lipoproteins
o Note: Immediate Density Lipoprotein (IDL)
enable fats and cholesterol to move within the
water-based solution of the bloodstream.
▪ Removal of triglycerides from VLDL by
muscle & adipose tissue results in the
formation of IDL particles which are
enriched in cholesterol. IDL particles
are pro-atherogenic.
ATHEROSCLEROSTIC CARDIOVASCULAR DISEASE (ASCVD)
• Goals of Dietary Management
o Total Fat - <30% of TER
▪ SFA 7-10%
▪ PUFA 10%
▪ MUFA 10%
▪ Cholesterol <200 mg/day
o Sodium - moderate intake
o CHO - type and amount depends on the lipid
abnormality
o Avoid high intake of alcohol
o To normalize blood lipid levels (NCEP III):
▪ TC <200 mg/dl
▪ LDL-C <100 mg/dl
▪ HDL-C >40 mg/dl (men); >50 mg/dl
(women)
▪ TG <150 mg/dl
o Weight control, through diet modification &
increase physical activity
• Nutritional Acuity Ranking - Level 3 (Moderate Role)
• Atherosclerosis - a specific type of arteriosclerosis,
when the blood vessels that carry oxygen and
nutrients from the heart to the rest of the body i.e.,
 arteries become thick and stiff – restricting blood flow ▪ Impaired Fasting Glucose
to the organs and tissues. Developed progressively ▪ Metabolic Syndrome
with inflammation and lipid accumulation. ▪ CVD Risk Factors:
• Some plaques are susceptible to rupture and • lipoprotein profile (LDL-C, TC,
promotes formation of blood clot within the artery HDL-C)
(thrombosis) • trimethylamine N-oxide
• When plaques rupture, leading to a blood clot (TMAO)
(thrombus), it can enlarge and obstruct blood flow. • Inflammatory Markers
• Portion of the clot (embolus) can travel through the (Fibrinogen, CRP, IL-6,
circulatory system and lodges in a narrowed artery Homocysteine)
and shuts off blood flow through the surrounding • Signs & Symptoms – Symptoms can also depend on
tissue (embolism) which artery is narrowed or blocked.
• The blockage can result in a myocardial infarction (MI) o Related to coronary arteries (heart) include
also called a heart attack which is due to necrosis of (Coronary Artery Disease):
cells as a result of oxygen deprivation; or an ischemic ▪ Arrhythmia, an unusual heartbeat
stroke also known as cerebrovascular accident (CVA) ▪ Pain or pressure in your upper body,
in the brain. including your chest, arms, neck, or
• ASCVD involves the narrowing of small blood vessels jaw. This is known as angina.
that oxygenate the heart muscle caused by the build- ▪ Shortness of breath
up of plaque (atherogenesis) o Related to arteries that deliver blood to your
brain include (Cerebrovascular Accident):
▪ Numbness or weakness in your arms
or legs
▪ A hard time speaking or
understanding someone who’s talking
▪ Drooping facial muscles
▪ Paralysis
▪ Severe headache
▪ Trouble seeing in one or both eyes
o Related to arteries of your arms, legs, and
pelvis include (Peripheral Artery Disease):
▪ Leg pain when walking (intermittent
claudication)
▪ Numbness
▪ Tingling sensation
• Prevention
• Risk Factors o Mediterranean Diet (MeD) - For primary
o Non-modifiable Risk Factors prevention of atherosclerotic cardiovascular
▪ Age disease
▪ Sex ▪ Rich in protective foods (fruits,
▪ Family History of Disease vegetables, legumes, wholegrains, fish
▪ Genetics and olive oil)
▪ Menopausal Status ▪ Low in adverse dietary factors (fast
o Modifiable Risk Factors food, SSB, refined grain products and
▪ Obesity (BMI ≥30, WHR ≥ 0.95 (men) processed/energy-dense foods) with
or ≥ 0.86 (women) moderate alcohol intake
▪ Dyslipidemia o MeD Tool - Overall dietary pattern &
▪ Hypertension individual components reflect risk; higher
▪ Physical Inactivity score is negatively associated with CVD and
▪ Atherogenic Diet all-cause mortality
▪ Cigarette Smoking o Diet and Lifestyle Change:
▪ Stress ▪ Saturated Fats - intake to 5% to 6%
▪ Diabetes
 ▪
Trans Fatty Acids – avoid; is inversely nasopharyngitis, sinusitis,
associated with HDL Levels and abnormal liver function
tests.
▪ MUFA - serum cholesterol levels,
LDL and TC levels Probucol Lowers the level of Bloating.
cholesterol in the nausea and vomiting.
▪ PUFA - Replacing PUFAs for CHO bloodstream by increasing stomach pain.
results in decline in serum LDL-C the rate of LDL catabolism.
Additionally, probucol may
▪ Omega-3 FA - TG levels by inhibiting inhibit cholesterol
VLDL and has anti-inflammatory synthesis and delay
cholesterol absorption.
effects; considered as cardioprotective
as they interfere with blood clotting; Anticoagulants heparin or warfarin (also Limit vitamin-K containing
stimulates production of NO2 which (Coumadin) called Coumadin), slow foods to 1 per day,
down your body's process consistency of intake is
relaxes the blood vessel (vasodilator). of making clots. often more important than
▪ Fiber - high intake lowers ASCVD and Antiplatelets, such as quantity. Decrease
aspirin and clopidogrel, supplements containing Vit
stroke due to the effects of soluble prevent blood cells called A,C,E which counters the
fiber (binds bile acids which lower platelets from clumping medication.
together to form a clot.
cholesterol, and bacteria in the colon
ferment fiber to produce acetate, Calcium channel preventing calcium from fatigue and swelling in the
blockers entering the cells of the abdomen, feet, and legs
propionate, butyrate, which inhibit heart and arteries. Calcium
cholesterol synthesis) causes the heart and
arteries to squeeze
▪ Antioxidants - prevents oxidation of (contract) more strongly.
PUFAs in the cell membrane; found in By blocking calcium,
calcium channel blockers
phytochemicals which improve allow blood vessels to
vascular activity relax and open.
▪ Stanol and Sterols - inhibits • Nutrition Management
cholesterol absorption o Plant Stanols and Sterols:
▪ Weight loss - obesity raises the risk of ▪ Made from naturally occurring
HTN, dyslipidemia, T2DM, ASCVD, substances in nuts, vegetable oils,
stroke. corn, rice, and other plant foods.
• Medical Management ▪ They block the absorption of
o Pharmacologic Management - Determination cholesterol & help LDL cholesterol
of drug therapy depends on risk category & levels without affecting HDL
attainment of the LDL cholesterol goal cholesterol levels.
DRUG CLASS FUNCTION POSSIBLE SIDE EFFECTS/ ▪ Studies have shown 2-3 grams of
INTERACTION
stanols or sterols LDL cholesterol up
Bile acid Adsorbs bile acids Colestipol (Colestid) to 10 to 14%. Most of these studies
sequestrants Block bile acid in your requires supplements of
stomach from being fat-soluble vitamins.
have been done on spreads containing
absorbed in your blood. Colestyramine (Questran) the ester forms (margarine spreads,
requires increased fiber
intake to alleviate
orange juice, milk, bars, and baked
constipation. Folate may products.)
also be used
▪ In order to get the full cholesterol-
Nicotinic Acid Inhibits a hormone- May cause nausea, lowering benefit, include 2-3 grams of
sensitive lipase in adipose vomiting and cramping sterol equivalents EVERY day. (1-gram
tissue which reduces the
breakdown of triglycerides stanol or sterol ester is equivalent to
to free fatty acids, and the 0.6 grams phytosterol).
transport of free fatty
acids to the liver ▪ Plant sterols and stanols have a similar
chemical structure to cholesterol.
Statins or 3-hydroxy- Inhibit the rate-limiting May cause constipation,
3- methylglutaryl- enzyme in cholesterol flatulence and GI
They are thought to work by reducing
coenzyme synthesis discomfort. Avoid the absorption of cholesterol in the
grapefruit which may
enhance drug effects
gut so more is lost in the feces (poo).
This helps to lower total cholesterol
Fibric acid may increase the level of common adverse effects and non-HDL cholesterol (the bad
derivatives HDL, while lowering liver include headache,
production of LDL dizziness, back pain, cholesterol) in the blood.
diarrhea, dyspepsia,
• Therapeutic Lifestyle Change (TLC) Diet - recommends
limiting serving sizes or replacing foods high in
saturated fat and cholesterol with healthier options.

o Emphasizes reducing dietary cholesterol (<200

mg/day), saturated fats (<7% of total calories),
and trans fats (lower intake). Total fat
comprises 25–35%