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Patient Profile and Medical Records DataAge= 50 yearsSex= MaleEthnicity= African AmericanOccupation= High School Football CoachHeight= 6 feet 3 inchesWeight= 220 lbsBP= 160/100Medical Hx= Stage 2 (essential) HypertensionP.A.= Walks 30 mins, 4-5 times per weekPreviously a 2- pack a day smokerPrevious Dietary Tx= 4-gm Na DietPharmacological Tx = 25 g hydrochlorothiazide qd
Patient Profile and Medical Records Data Chief Complaint:Difficulty in adhering to a reduction of salt in the diet. Food tastes bland and tasteless.
Pathophysiology of Hypertension• Hypertension is the chronic elevation of blood pressure that, in the long-term, causes end-organ damage and results in increased morbidity and mortality.• Occurs due to the abnormal functioning of the arterial pressure related to the central nervous system, renin-angiotensin-aldosterone system, endothelial dysfunction, genes and even due to certain environmental factors.
Pathophysiology of Hypertension• Factors which contribute to the development of hypertension are: Aging Genetics Obesity Smoking Salt Sensitivity High Frequent Alcohol Consumption High Fat Diet Low Fiber Diet• Normal blood Pressure is calculated as: 120/80 in healthy adults.
Pathophysiology of Hypertension• Resting Blood Pressure ≥ 140/90 on two separate occasions in an individual is characterized as either Stage I or Stage II Hypertension.• Resting Blood Pressure ≥ 130/80 in diabetic patients increases their risk for the development of heart disease.
Anthropometrics• BMR = 66 + (13.7 x 100kg) + (5 x 190.5cm) – (6.8 x 50) x 1.48 = 66 + 1370 + 952.5 – 340 x 1.48 = 2048.5 x 1.48 = 3031.8 kcals/ day• EER = 864 – (9.72 x 50) + PA x (14.2 x 100) + (503 x 1.905) =864 – 486 + (PA x 1420 + 958.2) =378 + (PA x 2378.2) =378 + (1.27 x 2378.2) =378 + 3020.3 =3398.3 kcals/ day
Biochemical Biochemical Patient value – mg/dl Normal value – mg/dl parameterTotal cholesterol 300 140-199LDL cholesterol 135 <130HDL cholesterol 35 37-70 Triglycerides 250 35-160
Biochemical• Altered Lipid Values as a result of: 1) High Saturated Fat and Trans-Fat Intake 2) High Sugar Intake 3) High Alcohol Intake 4) Overweight
ClinicalHealthy, male who looks his ageTemp= 98.6 0F BP= 160/100 mmHgHR= 80 bpm RR= 15 bpmRegular rate and rhythm, normal heart sounds (Noclicks, murmurs, or gallops)No edema present on the skin and on hands and feet
Clinical• Diagnosis of Stage 2 (Essential) Hypertension 1 year ago• Medical History shows that the subject’s mother died from a Myocardial Infarction Related to Uncontrolled Hypertension• Hypertension of subject may have been caused due to genetic history of hypertension
Dietary- History24-hr RecallUsual dietary intake:AM: 1 c coffee (black) Hot (oatmeal with 1 tsp margarine and 2 tsp sugar) or cold (Frosted Mini- Wheats) cereal. ½ c 2% milk 1 c orange juiceSnack 2 c coffee (black) 1 glazed donutLunch: 1 can Campbell’s tomato bisque soup 10 saltines 1 can diet colaAfter work: 2 (usually) gin and tonics (3 oz gin with 5 oz tonic)PM: 6 oz baked chicken (white meat no skin) (seasoned with salt pepper, garlic) 1 large baked potato with 1 T butter, salt and pepper 1 c glazed carrots (1 tsp sugar, 1 tsp butter) Dinner salad with ranch – style dressing (3 tsp)- lettuce, spinch, croutons, sliced cucumberHS snack: 2 c butter pecan ice cream
Recognition of Diet/ Drug Interaction• High intakes of salt in the diet increases the excretion of Potassium while taking hydrochlorothaizde can lead to development of hypokalemia• High intakes of Caffeine while taking hydrochlorothaizde can lead to a strong diuretic effect on the body thereby leading to dehydration• Untreated dehydration can lead to heart injury, cerebral edema, kidney failure, hypovolemic shock and even death.
Nutritional Needs CalculationsCHO requirements = 45% - 65% based on a 2000 calorieintakeIf 45% - 65% of carbohydrates are recommended based ona 2000 calorie intakeX % - Y of carbohydrates are recommended based on a3031.8 calorie intake X% - Y% = (45% - 65%) * 3031.8 / 2000 = (136,431% - 197,067) / 2000 = 68.2g – 98.5g
Nutritional Needs Calculations• PRO requirements = 10% - 35% based on a 2000 calorie intakeIf 10% - 35% of proteins are recommended based on a 2000calorie intakeX % - Y of proteins are recommended based on a 3031.8calorie intake X% - Y% = (10% - 35%) * 3031.8 / 2000 = (30,318% - 106,113) / 2000 = 15.2 g – 53.1g
Nutritional Needs CalculationsFAT requirements = 40% - 65% based on a 2000 calorieintakeIf 40% - 65% of proteins are recommended based on a 2000calorie intakeX % - Y of proteins are recommended based on a 3031.8calorie intake X% - Y% = (40% - 65%) * 3031.8 / 2000 = (121,272% - 197,067) / 2000 = 60.6 g – 98.5 g
Nutrition Diagnosis• Overweight as related to high carbohydrate and fat diet as evidenced by BMI of 27.56 and % IBW of 112.24 %.• Altered nutrition related laboratory values related to high fat diet as evidenced by total blood cholesterol of 300mg/dL, blood triglycerides of 250mg/dL, LDL of 135mg/dL and HDL of 35mg/dL.• Altered metabolic status (hyper) related to high salt and fat intake, family history of hypertension as evidenced by blood pressure of 160/100 mmHg and death of patient’s mother from MI related to uncontrolled hypertension.
Nutrition Diagnosis• Inadequate mineral intake (Potassium and Calcium) related to low dietary intake as evidenced by dietary intake of 81.1% Potassium and 84.2% Calcium.• Low adherence to nutrition recommendations related to patient’s low adherence to a 4mg sodium diet as evidence by chief complaint of foods being bland and tasteless.
Nutrition Care PlanProblem Goal Strategies Monitoring and EvaluationOverweight To achieve a weight To provide a 2925 24 hr recall, food loss of 20-22 lbs in 10 kcal/day low sodium frequency months. and Low fat, questionnaire, reduced diet. monthly weight check-up.Altered nutrition The patient will To provide a diet To monitor pt.related laboratory achieve lower low in lipids laboratory values.values laboratory values to (saturated fat and reach normal range. cholesterol) and to Cholesterol = 140-199 increase daily mg/dL physical activity LDL-C = < 130 mg/dL levels. HDL-C = >40 mg/dL To educate pt. on TG = 35-160 mg/dL choosing foods low in saturated fat, cholesterol and triglycerides.
Nutrition Care PlanProblem Goal Strategies Monitoring and EvaluationAltered metabolic status Patient should achieve a To increase activity Monthly blood pressure(hyper) normotensive BP of (aerobic) to 60 minutes, 5 measurements, food ≤ 120 mmHg times/week. frequency questionnaire 80 To provide a low sodium and 24-hr recall. diet (< 2300 mg/day) – based on the DASH Diet. To decrease the consumption of fast foods on weekends from Fridays and Saturdays once/week to Fridays and Saturdays once every 3 weeks. To increase consumption of low sodium home cooked meals.
Nutrition Care PlanProblem Goal Strategies Monitoring and EvaluationInadequate mineral To increase consumption To provide a diet rich in Food frequencyintake (Potassium (K) of foods rich in K and Ca. K and Ca using foods questionnaire, monthlyand Calcium(Ca)) such as low-fat dairy biochemical tests. products (Ca), mango (K), tomatoes (K), tomatoes (K), leafy green vegetables (Ca and K), fish (K).Low adherence to To increase adherence to a To provide nutrition Food frequencynutrition related low sodium diet. education and questionnaire, 24-hrrecommendations counselling on the recall. importance of adherence to a low sodium diet to patient and patient’s wife.
MenuBreakfast:2 servings of whole wheat cereal2 servings of a medium sized banana (sliced)2 servings of 1% or low fat milk1 serving of garlic teaSnacks: (AM)1 large mango1 20oz bottle water
MenuLunch:2 servings of mackerel (steamed / lemon)3 servings of whole wheat pasta1 serving of cooked pigeon peas2 servings of vegetables – 1 toss salad (1c lettuce, carrots)1 serving of olive oil3 servings of vegetable / fruit juice – beet root (1.5 serv) &pineapple juice (1.5 serv)Snack: (PM)1 20oz bottle water1 medium orange3 servings of Trail Mix
MenuDINNER:4 servings of whole wheat bread (Home-made, lowsodium)1 serving tomatoes1 serving lettuce1 serving salmon1 cup of water (8oz)
ReferencesLife Extension. 2012. “Risk Factors for High Blood Pressure.” Accessed November 10 th, 2012. http://www.lef.org/protocols/heart_circulatory/high_blood_pressure_04.htm.Mahan, L. Kathleen, and Escott- Stump, Sylvia. 2008. Krause’s Food and Nutrition and Diet Therapy. 12th edition. Philadelphia: W.B. Saunders Co.United States Department of Agriculture. (N.d.) “SuperTracker” Accessed 3rd November, 2012. https://www.supertracker.usda.gov/default.aspx.Vanlterson, Erik. 2010. “Proper Nutrition for Hypertension Patients.” Livestrong.com. November 2nd. Accessed November 12th, 2012. http://www.livestrong.com/article/295001-proper- nutrition-for-hypertension-patients/.Weber, Craig. 2009. “Diabetics and High Blood Pressure.” About.com. July 23. Accessed November 10th, 2012. http://highbloodpressure.about.com/od/highbloodpressure101/a/diabetes-hbp.htm.