Case Study #4

I. Understanding the Disease and Pathophysiology

1. Define blood pressure and explain how it is measured.
Blood Pressure is expressed as the measurement of systolic blood pressure (the
first and high number/ contraction phase) over diastolic pressure (the second and
lower number/ relaxation phase). Blood pressure can be measured using a
sphygmomanometer and stethoscope. The Sounds of Korotkoff can be heard, this
method allows you to hear the swishing of blood against arteries, and is
significant because when you hear the first sound through the stethoscope that is
systolic pressure and when that sound stops is indicative of diastolic pressure.
(Fusilero-Savoie).

2. How is blood pressure normally regulated in the body?

Blood pressure is normally regulated by the sympathetic and parasympathetic
nervous system, the renin-angiotensin-aldosterone system (RAAS) and renal
function (Fusilero-Savoie).

3. What causes essential hypertension?

Essential hypertension is also called primary hypertension meaning that it may
have resulted from an individual’s differences in RAAS control of blood pressure,
genes that affect sodium retention and lifestyle choices, which accounts for the
majority of all cases. Secondary hypertension occurs from another primary
problem such as renal disease, CVD, endocrine disorders and neurogenic
disorders (Fusilero-Savoie).

4. What are the symptoms of hypertension?

Due to lack of symptoms, hypertension is referred to as the silent killer because it
often goes undiagnosed without any visible symptoms. However, in some cases
when an individual experiences symptoms such as a severe headache, fatigue,
chest pain, irregular heart beating, and difficulty breathing it can be linked to very
high blood pressure (Fusilero-Savoie).

5. How is hypertension diagnosed?

Hypertension is diagnosed based on systolic pressure/ diastolic pressure. Normal
BP is <120/80, Hypertension Stage 1 is 130-139 systolic / 80-89 diastolic and
Hypertension Stage 2 is >140 systolic / >90 diastolic (Fusilero-Savoie).

6. List the risk factors for developing hypertension.

 Risk factors include excessive sodium/ low potassium intake, physical inactivity,
cigarette smoking, excessive alcohol consumption, and stress, as well as family
history of premature CVD, age, obesity, dyslipidemia, diabetes mellitus, and
microalbuminuria (Fusilero-Savoie).

7. What risk factors does Mrs. Sanders currently have?

A discontinued diet of low-salt foods, has a family history of HTN, mother died
of myocardial infarction due to uncontrolled HTN.

8. Hypertension is classified in stages based on the risk of developing CVD.

Complete the following table of hypertension classifications.

Blood Pressure mmHg

Category Systolic BP Diastolic BP

Normal <120 and <80

Prehypertension 120-129 or <80

Stage 1 Hypertension 130-139 or 80-89

Stage 2 Hypertension >140 or >190

9. How is hypertension treated? ()=related to case study

There are several ways to treat hypertension; pharmacological Tx
(Hydrochlorothiazide), smoking cessation (quit one year ago), weight reduction (-
10 lbs) and other lifestyle modifications such as diet, physical activity (began a
walking program), moderation of alcohol consumption (2-4 beers/wk) and stress
management.

10. Dr. Thornton indicated in his note that he will “rule out metabolic syndrome.”
What is metabolic syndrome?
Metabolic syndrome is a combination of metabolic risk factors, including
abdominal obesity, insulin resistance, dyslipidemia, hypertension, and
prothrombotic state, a state in which the formation of blood clots is facilitated.
You must have 3 of 5 risk factors to have metabolic syndrome.

11. What factors found in the medical and social history are pertinent for determining
Mrs. Sanders’s CHD risk category?
 Her family history, her history with smoking 2 packs of cigarettes a day before
cessation, the amount of alcohol she consumes and her diet.

12. What progression of her disease might Mrs. Sanders experience?

May be at risk for developing COPD, CVD, CHF, MI.

II. Understanding the Nutrition Therapy

1. Briefly describe the DASH eating plan
It stands for “Dietary Approach to Stop Hypertension”. It consists of a diet rich in
potassium, magnesium, fiber, protein, and calcium. Following this diet also calls
for decreasing amounts of sodium, trans/sat fat, and cholesterol intake. Also limit
sugar-sweetened beverages, sweets, fatty meats, and oils high in saturated fat.

2. Using the EAL, describe the association between sodium intake and blood
pressure.
Sodium intake directly affects blood pressure.The EAL recommends to counsel
patients on reducing sodium intake for blood pressure in adults with hypertension.
The recommendation is to lower dietary sodium intake to roughly 1200 mg-1500
mg per day to reduce systolic and diastolic blood pressure up to 12mm Hg and
6mm Hg.

3. 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.
Weight loss that reduces weight circumference and adjusts to a normal range of
BMI has proven to help lower blood pressure, especially if one loses 10% of body
weight in 6 months or ½-1 lbs a week.
Increased physical activity to lower blood pressure.
Counseling and education about lowering blood pressure.

III. Nutrition Assessment

1. What are the health implications of Mrs. Sanders’s body mass index?
She is barely overweight, her BMI of 25.8 is slightly higher than the highest
normal BMI of 24.9. Although she is slightly overweight, it can still affect her
health. Being overweight has been linked to hypertension, it has been proven that
losing 10 kg will result in lowering your systolic blood pressure 5-20 mm Hg.

2. Calculate Mrs. Sanders’s resting and total energy needs.

Mrs. Sanders’s resting energy needs can be calculated using Mifflin-St. Jeor
equation:
 10*W+6.25H-5A-161 where weight is in kg, height is in cm, and age in years.
10*72.7+6.25*167.64-5*54-161= 727+1047.75-270-161= 1343.75 (1350)
calories.
1350 calories are within the calories range needed to lose weight (1200-1500
calories a day). Keeping this amount of calories will benefit the patient in
reducing body weight and as a result BMI. To succeed in consuming this amount
of calories, Mrs. Sanders should concentrate on food high in potassium,
magnesium, fiber, and calcium. For example green and colorful vegetables, fruits,
nuts, seeds, lean meats, poultry, plant-based fat, and whole grains. Alcohol and
sodium should be limited.

3. What nutrients in Mrs. Sanders’s diet are of major concern to you?

Ice Cream- high sugar content “sweet”
Pizza- high sat/trans fat
Steak- red meat, high cholesterol
Beer- ETOH
Donut- high sugar content “sweet”
Canned tomato soup and saltine crackers- High sodium containing foods
Diet soda- sweetened beverage

4. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic terms.
Excessive energy intake, excessive fast food consumption, excessive sodium
intake, inadequate potassium, magnesium intake, less than optimal intake of
unsaturated fats, inadequate fiber intake.

5. Dr. Thornton order 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 Pt’s Value Reason for Nutrition

Abnormality Implication

Glucose 70-110 mg/dL 115 Elevated DM

BUN 8-18 mg/dL 22.2:1 Elevated Heart failure

Dehydration
High protein diet

Creatinine 0.6-1.2 mg/dL 0.9 n/a n/a (high creatinine

can mean kidney
 failure)

Total cholesterol 120-199 mg/dL 270 Elevated CAD

Stroke
Atherosclerosis

HDL-Cholesterol >55 mg/dL F 30 Very low CAD

>45 mg/dL M Stroke
Atherosclerosis

LDL-Cholesterol <130 mg/dL 7.0 Elevated CAD

Stroke
Atherosclerosis

Apo A 101-199 mg/dL F 75 Very low CAD

94-178 mg/dL M Stroke
Atherosclerosis

Apo B 60-126 mg/dL F 140 Elevated CAD

63-133 mg/dL M Stroke
Atherosclerosis

Triglycerides 35-135 mg/dL F 150 Elevated DM

40-160 mg/dL M Heart attack
Stroke
High BP

6. Interpret Mrs. Sanders’s risk of CAD based on her lipid profile.

Mrs. Sanders has a high risk for CAD. Her lipids are highly elevated along with
her LDL cholesterol, total cholesterol, and apolipoprotein B. She also has a very
low level of HDL cholesterol and apolipoprotein A.

7. What is the significance of apolipoprotein A and apolipoprotein B in determining

in a person’s risk of CAD?
Apolipoprotein A is associated with HDL cholesterol and apolipoprotein B is
associated with LDL. Apo-B is the protein component of LDL so it is responsible
for the binding of low-density lipoprotein to the receptors and for transporting
cholesterol to the cells. Therefore, increased levels of apolipoprotein B in the
plasma is directly related to the development of CAD (Ogedegbe, 2002).

8. Indicate the pharmacological differences among the antihypertensive agents listed

below
Medications Mechanism of Action Nutritional Side Effects
and Contraindications

Diuretics Inhibits Na+, Cl- & K+ Decrease K+

Reabsorption Anorexia
Increases prostaglandins Increase blood glucose
Prevent Na+ & K+ Avoid natural licorice
exchange
Decrease aldosterone
stimulation

Beta-blockers Block B receptors in the N/V

heart Diarrhea
Decrease rate and output Avoid natural licorice

Calcium-channel blockers Affect Ca+ movement Edema

Relax blood vessels Nausea
Heartburn
Limit caffeine
Limit ETOH

ACE Inhibitor Block angiotensin Avoid natural licorice and

converting enzyme salt substitutes

Angiotensin II receptor Block activation of Dizziness, elevated blood

blockers angiotensin 2 AT 1 K+ level, angioedema.
receptor (it causes Avoid grapefruit and
vasodilation) licorice

Alpha-adrenergic blockers Acts as antagonists on a- Contraindication: urinary

adrenergic receptors; incontinence, fluid
decreases stroke volume retention, benign prostatic
and inhibit sympathetic hyperplasia; interacts with
muscular stimulation a-blockers. Avoid licorice.
Common side effects
include
constipation/diarrhea and
mouth dryness

9. What are the most common nutritional implications of taking

hydrochlorothiazide?
Hydrochlorothiazide also is known as thiazides increase loss of zinc, potassium,
and magnesium. This diuretic also decreases blood levels of folic acid and
increase a toxic amino acid byproduct homocysteine. According to some studies,
people who take hydrochlorothiazide are not advised to take hibiscus, licorice,
 dandelion, horsetail, and Ginkgo should be taken with caution (Kaiser
Permanente).

10. Mrs. Sanders’s physician has decided to prescribe an ACE inhibitor and an HMG-
CoA reductase inhibitor (Zocor). What changes can be expected in her lipid
profile as a result of taking these medications?
Both ACE and HMG-CoA inhibitors are expected to be helpful in improving Mrs.
Sander’s lipid profile. Zocor is an example of simvastatins. Simvastatins are
lipophilic compounds that easily across the cell membrane of extrahepatic tissues
inhibiting HMG-CoA reductase. This inhibition leads to reduced production of
total cholesterol and as a result lower plasma LDL-cholesterol (Shuhaili,
Samsudin, & Stanslans, 2017).
Similarly, ACE inhibitors are shown to reduce total cholesterol and increase
plasma HDL-cholesterol (Short Communicatio, The Journal of Science Society).

11. How does an ACE inhibitor lower blood pressure?

Physiologically, high blood pressure is caused by actions of angiotensin II that
makes blood vessels narrower creating constructs for blood to move. Furthermore,
angiotensin II stimulates secretion of aldosterone that is responsible for water
retention. These two events contribute to elevated blood pressure. ACE inhibitor
decreases the activity of angiotensin II causing a healthy blood flow through the
vessels and simultaneously it reduces actions of aldosterone leading to less water
retention and as a result lower blood pressure.

12. How does an HMG-CoA reductase inhibitor lower serum lipid?

HMG-CoA reductase is a catalytic enzyme in cholesterol synthesis that plays a
vital role in lipid homeostasis. HMG-CoA reductase inhibitor also known as statin
drug blocks the catalyst leading to less production of cholesterol. Reduced amount
of cholesterol subsequently decreases the total amount of cholesterol in the
bloodstream (Friesen & Rodwell).

13. What other classes of medications can be used to treat hypercholesterolemia?

Besides HMG-CoA reductase inhibitors (statins), hypercholesterolemia can be
also treated with vitamins (fenofibric acid, B-3-50, Fibricor), antihyperlipidemic
agents (Slo-Niacin, Niacor), bile acid sequestrants (Welchol), cholesterol
absorption inhibitors (Zetia), antihyperlipidemic combinations (Vytorin),
antihypertensive combinations (Atorvastatin), and PCSK9 inhibitors (Praluent)
(drugs.com).
14. What are the pertinent drug-nutrient interactions and medical side effects for ACE
inhibitors and HMG-CoA reductase inhibitors?

ACE inhibitors HMG-CoA reductase

inhibitors

Drug-nutrient Depletes zinc ->zinc Fat-soluble vitamins D,

interactions supplements are needed. E, K, A can be affected.
Intake of additional It is recommended to
potassium may lead to take CoQ10 supplement
hyperkalemia. Green tea since HMG-CoA
and Goldenseal may reductase syntheses
affect the therapeutic CoQ10. Both chemical
effect of ACE inhibitors. compound allicin in
Garlic and Ginkgo may garlic and Red Yeast
affect the excretion of Rice may lower
the drug. effectiveness of the drug.

Medical side effects Dry cough, dysgeusia, Cognitive decline,

dizziness, fatigue, muscle pain, increased
hyperkalemia. risk of DM, liver
Contradictions: dysfunction
pregnancy
According to *Pharmavite LLC and Mayo Clinic

15. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic terms.

Nutrition problems associated with elevated blood glucose include diabetes

mellitus which can be linked to the uncontrolled consumption of high
carbohydrate foods. Improper regulation may result in weight gain, insulin
resistance, high fasting BG, or worse, amputation of a limb or loss of vision.

BUN measures the amount of nitrogen in the blood that comes from urea. Urea is
made in the liver and is created when is protein is broken down. A high BUN can
indicate that the kidneys are not functioning properly because they are not doing
their job to remove the urea from the blood. This can also result from heart
failure, dehydration or a high protein diet. However, because the creatinine levels
are within normal range, which can also tell how well the kidneys are working,
this raise in level might be from dehydration. Dehydration can lead to rapid heart
 rate, lethargy, confusion, low blood pressure, and dizziness. If it is severe, it can
lead to coma and seizures (American College of Cardiology).

Mrs. Sanders’s triglyceride level is high. High triglyceride levels indicated when
there is an elevated amount of fat in the blood. Nutrition problems related to high
triglycerides include prediabetes or type II diabetes, and metabolic syndrome.
High triglycerides can also be a side effect of taking hydrochlorothiazide, which
is a diuretic. From Mrs. Sanders’s chart, she might have metabolic syndrome from
her results of high blood pressure, high triglycerides, high blood sugar, and
abnormal cholesterol levels (Triglycerides: Why Do They Matter?). All of these
are very serious and can lead to heart disease, stroke, and even death.

Nutrition problems related to high total cholesterol include Coronary Heart

disease and Peripheral arterial disease, when cholesterol is high it can build up on
the walls arteries and can build up to atherosclerosis which causes arteries and
blood vessels to be narrowed or blocked by buildup of plaque, resulting in
reduced blood flow to the heart and brain or vessels outside the heart and brain.
T2DM is also linked to high cholesterol, even if blood sugar control is good,
people with diabetes tend to have increased triglycerides, decreased high-density
lipoprotein (HDL), and sometimes increased low-density lipoprotein (LDL). This
increases the likelihood of developing atherosclerosis (“High Cholesterol
Diseases”, 2016). As previously stated in question #7 apolipoprotein A is
associated with HDL cholesterol and apolipoprotein B is associated with LDL.
Apo-B is the protein component of LDL and is responsible for the binding of low-
density lipoprotein (LDL) to the receptors on the cell membrane of cells and for
transporting cholesterol into the cells. Therefore, increased levels of
apolipoprotein B in the plasma is directly related to the development of CAD
which is related to the build up of fatty deposits along the artery walls.
(Ogedegbe, 2002).

16. What are some possible barrier to compliance?

She was diagnosed with hypertension a year ago and the informational sheet
about a low sodium diet the nurse gave her wasn’t well accepted. She and her
husband tried the diet but they felt that the foods were bland and had no taste so
they gave up on the diet. Due to her trial and error with the diet, she may be
resistant to trying again.

IV. Nutrition Diagnosis

1. Select two nutrition problems and complete the PES statement for each.
 PES #1 Excessive sodium intake related to the consumption of fast food and
ignorance of DASH Eating plan as evidenced by blood pressure of 160/100
mm/Hg.
PES #2 Inadequate fiber, potassium, and magnesium intake related to
consumption of a high amount of processed carbohydrates as evidenced by
elevated cholesterol level (210 mg/L), low HDL level (38 mg/L), high LDL level
(147 mg/L) and blood glucose of 115 mg/L.

V. Nutrition Intervention
1. When you ask Mrs. Sanders 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.
Sanders?
This is an ambitious goal, at 54 years old it would be a challenge to lose 35
pounds. As the body ages, it becomes harder to lose weight, and it’s unrealistic to
want to achieve the weight she was in her prime years of age. According to the
data, losing 10 kg of body weight will lower blood pressure. I would not set an
ideal weight for her to achieve but I would suggest attempting to lose ½-1 pound
per week to try to reduce her blood pressure. I would also recommend exercise to
decrease body fat and increase lean muscle, but this may cause her weight to go
up in some instances after muscle has been gained. That is why a specific number
would not be recommended, but attempting gradual weight loss and exercise
would be the best recommendation.

2. How quickly should Mrs. Sanders lose this weight?

She should try to lose ½-1 pound per week.

3. 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).
PES #1: An ideal goal would be to reduce sodium intake and as a result lower her
blood pressure. Unfortunately, she tried the DASH diet but didn’t stick with it due
to the bland tastes. An appropriate intervention would be to give her some
resources about adding flavor to meals without adding excess salt. An example of
this would be to add fresh herbs to her meals. Another intervention to help her
reduce her sodium would be to limit eating fried foods and red meat to once a
week, due to her history she may be able to achieve this goal because she cooks
often and only eats fried foods and red meats outside of the home. If she complies
with the dietary changes and goals implemented by her care team, an attainable
 goal of lowering blood pressure to 140/100 could take place after a month on this
program.
PES #2: An ideal goal to increase levels of fiber, potassium, and magnesium
would be to implement high fiber and high water content foods to her diet.
Referring her to a handout that outlines foods high in fiber will help her to
understand what foods to buy at the grocery store and add into her meals she
cooks at home. Some examples of high fiber, potassium, and magnesium foods
include whole grains, spinach, bananas, and even dark chocolate. By suggesting a
different sweet after bingo night such as homemade dark chocolate covered
frozen bananas, this was an attainable goal because she could still satisfy her
sweet tooth but also increase her magnesium, potassium, and fiber intake.
Implementing an intervention that recommends substitutions or health additions
to her meals and snacks is a realistic goal for her to attain. If this intervention is
followed, in a month her care team should see a significant rise in these nutrient
levels.

4. Identify the major sources of sodium, saturated fat, and cholesterol in Mrs.
Sanders’s diet. What suggestions would you make for substitutions and/or other
changes that would help Mrs. Sanders reach her medical nutrition therapy goals?
Major sources of sodium include canned soups, saltine crackers, pizza, red meat,
and adding additional salt to her meals in the cooking process. Saturated fat and
cholesterol sources include pizza, steak, ice cream, donuts.
To reduce sodium levels, it is recommended to buy low sodium soups and low
sodium crackers, preferably whole grain crackers. Red meat should be an
occasional food, at the most once a week. Red meat should be substituted with
leaner meats like poultry or fish. Pizza should be a special treat consumed rarely
if craving pizza attempt to make it from home so ingredients can be monitored.
Lastly limiting additional salt as seasoning to food cooked at home, attempt to add
natural flavors like whole herbs and natural flavors. Reducing intake of sweets
like donuts and ice cream would be highly recommended, treats of that nature
should be substituted with healthier options. Ice cream should be low fat or made
with nut or soy milks. Donuts should be substituted with other less saturated
sweets. A strong recommendation for substituting sweets could be eating fruits
with whip cream or dark chocolate drizzle.

5. What would you want to reevaluate in three to four weeks at a follow-up

appointment?
Evaluating her weight, BMI, waist circumference, dietary changes, blood
pressure, alcohol use, exercise habits, lipid profile, blood glucose, hemoglobin
A1C, and electrolytes would be a good way to status her progress.
 6. Evaluate Mrs. Sanders’s labs at six months and then at nine months. Describe the
changes that have occurred.
Sodium: Her lab results exhibited a gradual incline by 1 mEq/L each time she was
seen by the doctor at 6 and 9 months. This does not seem like a largely significant
amount of change but over the entire time span the goal was for her to start
lowering her sodium, and it is seen in her lab results that her levels are rising.
Potassium: At her initial visit, she had 4.5 mEq/L in her lab results, after 6 months
it decreased by a whole point. It rose slightly at her 9-month lab but still showed
that from the first lab results her levels have dropped.
Glucose: At her first visit her lab results were over the normal range at 115
mg/dL. Six months later she was able to lower this number to 90 mg/dL which
was within normal range, at the 9 month mark it increased by 6 mg/dL which is
very close to the higher end of the normal spectrum.
Magnesium: Her first lab results were at a 2.1 mg/dL, after 6 and again at 9
months her results increased and stayed at a 2.3 mg/dL.
Cholesterol: When the patient was first seen her lab results about cholesterol were
well over the higher number in the reference range for cholesterol. She started at
270 mg/dL and was able to lower these levels at the 6 and 9-month mark. At 6
months she had lowered this number to 230 mg/dL, and by 9 months she
decreased her levels by another 20 mg/dL. Her most recent results are still higher
than the highest end of the reference range, but she has significantly lowered these
levels.
LDL/HDL: In both of these lab results she was able to lower her LDL levels after
9 months and increase her levels of HDL over 9 months.

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