Case Study

Katherine Podgwaite Introduction

Marfans Syndrome The primary medical condition of my patient is Marfans syndrome. This disease results from a genetic defect in fibrillin-1, and causes a connective tissue disorder. Marfans most noticeably presents itself through specific physical characteristics. Marfans patients, like this one, are often very tall and thin, with long arms and a long face. The patient is 64, and shows textbook physical characteristics of Marfans. Marfans can often be hard to diagnose, because height alone is not a good indicator. Most often, as in this patients case, Marfans will not be diagnosed until some of the other side effects of the disease are brought into light, most often cardiovascular. The defect in the connective tissue causes risk for many body systems to be affected such as the cardiovascular system, skin, eyes, bones, tendons, and cartilage. In this patients case, their cardiovascular system has been most effected, specifically their heart. If left untreated, it is not uncommon for heart problems such as MVP (mitral valve prolapse), palpitations, tachycardia, heart murmurs, aortic aneurysms and dilations, and angina pectoris. This patient had suffered from an aortic aneurysm that had to be surgically repaired as a result from the Marfans. The severe stress from the patients lifestyle and occupation has most definitely worsened the fatigue caused by Marfans and contributed to the weakness of their heart as well. Angina Pectoris Due to some of the cardiovascular affects of the patients Marfans syndrome, they have developed frequent angina pectoris, or, chest pains. The patient is a 55-year-old male, both of which are factors that contribute to higher risk for angina, in addition to the Marfans. The patient also has mild hypertension and tremendous stress in their activities of daily living, which only worsen the symptoms of angina pectoris. Angina pectoris most commonly presents itself as tightness or pain in the chest, but can also radiate to the arm, shoulder, jaw, and neck. Additional symptoms include tachycardia or palpitations, and abdominal discomfort. The most immediate risk for the patient is a myocardial infarction, which can be both fatal and prevented through change of lifestyle and nutrition intake. Angina can be treated through preventative measures such as eating a diet high in whole grains, fiber, fruits, fish, and vegetables and low in sodium and saturated fats, maintaining weight, controlled blood pressure, low stress physical activity, and relaxation.

Case Study Case Study

Katherine Podgwaite

Abraham Lincoln is a 55-year-old male who is President of the United States of America, and currently resides in the White House in Washington, DC. Over the past 10 years, he has been experiencing heart palpitations until 2 years ago, when he was brought to the hospital for an aortic aneurysm repair. Mr. Lincoln was diagnosed with Marfans syndrome soon thereafter, and has recently been experiencing reoccurring chest pains, called angina pectoris. Since then, his cardiologist, who has been unsuccessful in convincing Mr. Lincoln to accept treatment, has referred him to my Dietetics and Nutrition Therapy practice. Mr. Lincoln has refused all medications and treatment previous to his arrival at my practice. Mr. Lincoln lives with his wife, Mary, and their two children in the hub of the city of Washington DC. He was first elected President 5 years ago, and was re-elected again, just last year. His first term serving the nation was stressful to say the least, and not all people were supportive. Although Mr. Lincoln and his family are financially stable, there has been an instability in the nation as whole that has taken its toll. From morning to night, Mr. Lincoln is constantly concerned with the problems of the nation, and does not put much thought into taking care of himself. He often forgets to eat, and when he does remember to eat, most of his meals are quick and left half finished; usually at his desk while reviewing a bill or letter of legal document. This has led to weight fluctuation. Since the birth of their last child, Mary has been insisting that her husband should spend more time with her and the children. Their family had already suffered through the lost of two children, and Mr. Lincoln and his wife has been devastated ever since. Mr. Lincoln occasionally struggles with bouts of depression, and feelings of loneliness. Because of recent events developing in the country, Lincoln, stretched between his family and his nation, has not had much time to sleep, let alone engage with his wife and two children. As he faces the nation head on in his day-to-day activities, Mr. Lincoln experiences a considerable amount of anxiety. He hardly gives much thought to his health, and has previously attributed his unnatural height and long arms to an excess of milk in his younger years. Since his surgery and diagnoses of Marfans syndrome, Mr. Lincoln has made no effort to seek out health care options and has refused all medications. He attests this to his determination and tireless work ethic in his dedication to his people and this nation. Mr. Lincoln does not have the freedom and time to be frequently consulting with doctors, and has refused prescribed medications due to religious beliefs. He believes profoundly in Gods will and healing, and has also drawn his position as President for equality among men from his belief in God. Mr. Lincoln is well educated and passionate, but is very stubborn and incessantly preoccupied with other matters. It will be extremely difficult to advise and change behavior to address health concerns in Mr. Lincolns case, due to his time and attention consuming job and lifestyle. If Mr. Lincoln is not proactive in getting his health under control, the combination of stress and refusal to manage his disease could be fatal.

Case Study

Katherine Podgwaite Problem Based Questions

1. What is angina pectoris? Angina pectoris is just a fancy name for these chest pains you have been having. It results from a restriction of blood flow to your heart can be caused by many different factors. In your case, it is caused by Marfans Syndrome and the stress you experience in your every day life. Fortunately, you can manage and greatly improve your chest pains by making some dietary and lifestyle changes. 2. I am already set in the regimen I have. What will happen if I dont want to change my diet? Well, your Marfans Syndrome has weakened your heart, since it had gone undiagnosed for quite a while before the past few years. That is what caused your aortic aneurism, which has lead to your frequent chest pains. Without changing your diet, you would be susceptible to other resulting illnesses such as high blood pressure, heart murmurs or palpitations, rapid heart beat, an increase in frequency of chest pain, and even a heart attack. Even a few small lifestyle changes can help to prevent those things, and will definitely help you to feel well again. 3. You said theres no cure for Marfans Syndrome. Why should I change my diet if it wont cure me? Youre right, there is no cure for Marfans. However, making some dietary and other lifestyle changes could greatly improve some of the symptoms you have been having. The Marfans has made the connective tissue in your heart weak, which in addition to the stress has caused you to have these chest pains. By exercising 30 minutes a day and eating a diet higher in fruits and vegetables, whole grains, and low fat dairy, you can help reduce some of the stress on your heart, which will definitely improve the chest pain you have been experiencing. 4. I know I should be eating more fruits and vegetables. Does that mean I have to give up all of my favorite foods? Absolutely not! Its true, some of the dietary changes include eating more fruits and vegetables, but you do not need to give up your favorite foods as well! The goal is to eat a well balanced diet and to incorporate more healthy foods, rather than to take away some foods. You even have the option of altering your favorite foods to make them healthier and taste great! 5. I heard that people with heart problems have to eat less salt. Does this apply to me as well? Yes, to an extent. The daily recommended intake of sodium, which is a major component of table salt, for the general population is about 2,300 mg per day. In your case though, we would want to follow the American Heart Association guidelines, which are specifically tailored to patients with heart problems or are at risk for heart problems. The AHA recommends that you consume 1,500 mg of sodium per day, which is more than enough for the needs of your body.

Case Study

Katherine Podgwaite

This will help stabilize your blood pressure, and will put less stress on your heart, allowing you to have better control of managing your chest pains. It can be difficult to think about lowering your dietary sodium intake, but one good tip is to ask for your food to be prepared with lesser amounts of salt. This way, you consume sodium in a more controlled fashion. 6. I feel like I dont have time to think about what I eat. How do I make changes when I already have so much else on my plate? I understand you are feeling stress associated with making some of these life changes. That is completely normal, making some of these changes can sound impossible! The important thing to keep in mind is that you are making the changes for your own health. You can start by setting aside some time to think about the changes that you might be ready to make, and how your family can help you to make them. Since your meals are prepared for you, you can ask the chefs to follow some of these dietary changes when preparing your food. Keeping a bowl of fruit or healthy snacks out at all times will increase the likelihood of you increasing your fruit intake. Lastly, eating at the dinner table will ensure that you eat a full, proper, well-balanced meal that provides a wide variety of nutrients. Critical Issues Positive 1. Mr. Lincoln is very financially stable, and will be able to afford the treatment, care, and lifestyle changes recommended to him by his cardiologist and dietitian. 2. Mr. Lincoln has a supportive wife and two children. Not only will he have support in making these changes, but will also allow him to share and grow closer with his family by working together to improve his health. 3. Mr. Lincolns dietary changes are something he can actively have control over, which can contribute to lessening some of his stress and give him a sense of security and achievement. 4. Mr. Lincoln has chefs that prepare his food, and can tailor his meals specifically to meet his dietary needs. Negative 1. Mr. Lincolns Marfans is incurable, and will continue to weaken the connective tissue in his heart without medication. 2. The stress of Mr. Lincolns job demands a great amount of time, and adds to the stress on his heart. 3. Mr. Lincoln is stubborn and unwilling to make changes, putting him at risk for other severe medical complications. 4. The death of Mr. Lincolns children has caused him to struggle with bouts of depression. This has lead to eating and weight fluctuations.

Case Study Theoretical Issues 1. Health Belief Model

Katherine Podgwaite

This model embodies the development of counseling strategies, because it was one of the first health behavioral models, developed in the 1950s by Public Health Services social scientists. It was first used to test peoples non-compliance with taking medications as well as utilizing preventative measures for serious medical conditions and diseases. The Health Belief Model works off of the theory that an individuals belief of susceptibility to a certain condition or disease along with their belief in how effective preventative measures and treatments can be will influence whether they will take action or not. The Model identifies six different influences that determine an individuals decision to act. The first is that the person must believe that they are susceptible to the illness, and may have a chance of contracting it. Secondly, they must believe that this condition could be quite severe, and they would recognize the consequences if they left the condition untreated. Third, they must believe that choosing to take action and utilize preventative measures would be beneficial and effective. Fourth, the individual would recognize the hesitancy and obstacles that would prevent taking action, such as time, money, convenience, life changes, side effects, etc, and determine that the benefits of taking action would outweigh the cost. Fifth, the individual needs to be exposed to some sort of indicator that drives them to take action, whether it be their own symptoms or an add in the media. Finally, the individual must be confident in their ability to take this action. Mr. Lincoln is only newly becoming aware of the severity of his condition, and how other factors such as his age and daily life style can present risks on worsening his condition, or advancing and causing new medical conditions. He has been living his life in denial and ignorance of his health, and is now beginning to see the severity of his condition and how it will negatively impact his life if action is not taken. The Health Belief Model is a good tool to relate to Mr. Lincolns condition because it accurately portrays his new awareness, and the factors on his life preventing him from choosing to make dietary changes. Mr. Lincoln believes he does not have enough time to focus on his health and potential life changes. I believe that Mr. Lincolns severe chest pains have driven him to begin taking action, but that he still needs confidence in his ability to change his diet and get better. Specifically, the self-efficacy portion of the model describes Mr. Lincolns most prevalent underlying struggle in approaching change. I would encourage him that he will be able to make effective changes without it negatively affecting his job or life and ensure him that it is possible, and that we can take it one step at a time.

2. Behavior Theory This theory stems off of the development and research of Skinner and Pavlov. The theory is based off of the idea that new behaviors can be learned if environmental factors are altered. The theory is divided into three approaches: Classical Conditioning, Operant Conditioning, and Modeling. Classical Conditioning works by identifying cues that affect undesirable behavior, and then working to change or eliminate those cues. Operant Conditioning works to associate behaviors with positive and negative effects. For example, individuals might reward themselves with a desired object or indulgence for achieving a set goal. Lastly, Modeling involves an

Case Study

Katherine Podgwaite

individuals change of negative behavior as a result of observing anothers positive behavior. The ideal case is that the individual would change their behavior to mirror the desired behavior. Mr. Lincoln often struggles with weight fluctuations, due to his unpredictable eating patterns. He regularly skips meals and will leave them unfinished on his plate. He also tends to eat his meals while simultaneously doing work, and does not put much though into what he eats. In Mr. Lincolns case, Classical Conditioning would be a good approach to consider when striving for him to develop a better, healthier eating pattern. Unfortunately, Mr. Lincoln cues revolve around his work. He is so busy, that his work will take priority over eating. I believe that identifying cues such as multitasking eating and eating away from the dinner table can help Mr. Lincoln realize that his eating is problematic. Instead, I would suggest that he schedule time to sit down to a meal at a dining table three times per day. Additionally, I would recommend he keep a bowl of fruits or other healthy snacks within reach while he does his work, to encourage him to consume an adequate intake of food. I believe that Mr. Lincoln needs to take an active role in identifying his own cues and finding solutions that he would be ready to engage in.

3. Family Theory The family theory utilizes family counseling as an aid in assisting a behavioral change of an individual. Irvin Yalom developed this theory as to additive to other behavioral therapies, and it is still commonly used in practice. Having the support of significant family members as a good influence will help benefit the clients outcome. However, negative family influences can also be problematic, so the help of a psychologist is often needed when approaching a family therapy method. Mr. Lincoln has a wonderful wife and two children who have stuck by his side and supported him throughout his presidency. He also desires to have a better relationship with them, but has trouble connecting with them because of the demands of his job. I believe that family therapy would be a good supplement to Mr. Lincolns dietary and lifestyle changes because of the fact that they may be difficult and seem unimportant in the grand scheme of things. With the support of his wife and children, Mr. Lincoln and his family can work on making changes together, so that he does not feel alone or insignificant in his changes. Mr. Lincoln also seems to lack selfconfidence, another good reason why family therapy will give him the motivation and determination to try some of these lifestyle changes. I would need to work closely with a psychologist, as this approach is not my field of expertise. I would continue to encourage Mr. Lincoln in the steps he has taken so far to seek out medical help and support him in his ability to make further changes. Working with his family will be a good opportunity for Mr. Lincoln to not only gain support and guidance, but to grow closer to his family and see the benefits of the changes he is making to pursue a healthier lifestyle.

4. Transtheoretical Model The Transtheoretical Model is one of the most widely used behavior change models and it evaluates the behavior change process through an individuals readiness to change. It was

Case Study

Katherine Podgwaite

founded by Prochaska and DiClemente in the 1970s, and originally was used in a study to research the behavioral development behind smokers aspiring to quit. The model is composed of five (or, arguably six) different stages of behavioral change. The first stage, precontemplation, identifies with an individual who is either unaware or have no intention of changing a behavior that is producing negative results. They are often in denial of their behavior, and tend to be resistant to change. The second stage, contemplation, is when the individual is aware of the need for change. The problems of their behavior become evident, and the individual is beginning to consider the idea of changing within the next 6 months. The third stage, preparation, describes a time when the individual is determined to make a change within the next 30 days. The individual believes that making this change will lead to a positive outcome or healthier life style. In the fourth stage, action, the individual has made a behavioral change and is intending to continue to keep that lifestyle change. The fifth stage, maintenance, is reflective of the individual making an active change in behavior that has lasted 6 months or more, with the intention of continuing this change long term. The sixth stage, Termination or Adaptation, describes a total behavioral change, in which the individual has adapted the change as a new lifestyle and has no intention or indication of ever changing or relapsing. Mr. Lincoln is new to the idea of accepting his disease and becoming aware of the negative effects of his current behavior on his health. He has been oblivious to the severity of his condition so far, but now that he has become aware, he has begun to think about the benefits of changing. I believe that Mr. Lincoln would associate best with the contemplation stage. Despite the fact that he has resisted certain treatment methods from his cardiologist, he has also agreed to an appointment with me, his dietitian, and therefore has come seeking help and guidance. He seems unwilling at the moment to make any change within the next 30 days, but with time and counseling, I believe we can figure out the right approaches so that when he is ready to change. My goal is to continue to encourage him and talk about the changes he may be ready to make. Mr. Lincoln has great potential to move through the preparation stage to the action stage once we break down his health goals into more achievable objectives. I will begin to educate him and work together to formulate some small objectives he would like to achieve so that he can begin taking steps to improve his overall health. Counseling Goals and Objectives Goal 1: Mr. Lincoln will consume at least 2 full meals a day over the next 2 months. Objective Mr. Lincoln will eat at least 1 meal a day at the dinner table with his family at a 5:30 pm each day. Objective Mr. Lincoln will allow himself at least 30 minutes to consume each full meal. Objective Mr. Lincoln will limit his working during full meals to no more than 5 meals per week over the next 2 months.

Case Study

Katherine Podgwaite

Goal 2: Mr. Lincoln will consume at least 2 fruits and 2 vegetables a day over the next 2 months. Objective Mr. Lincoln will keep a bowl of fruit at his desk every day during his work hours over the next 4 weeks. Objective Mr. Lincoln will sign up in advance for a year of local farmers market produce program that would provide his household with various seasonal fruits and vegetables, so that he can experience and consume a wide variety of produce. Objective Mr. Lincoln will keep a food record over the next 4 weeks to ensure he has consumed the appropriate amount of produce to be reviewed by his dietitian upon his next visit. Goal 3: Mr. Lincoln will reduce his sodium intake to 2,300 mg per day over the next 4 months. Objective Mr. Lincoln will add no additional salt to his food over the next 2 months. Objective Mr. Lincoln will consume 2 high potassium foods per day, and record them in his food diary. Objective Mr. Lincoln will alter his food preparation by using various herbs and seasonings to flavor his food instead of excess salt over the next 6 weeks.

Assessment, Diagnosis, and Education Mr. Lincoln, like many patients, has more than one nutritional deficit. He struggles with consuming an adequate amount of food, in addition to the right kinds of food for his condition. Mr. Lincolns food history, including a 24-hr dietary recall revealed that his eating is sporadic relative to his stress levels. He also seemed to have a lack of education on what foods could help with the symptoms of his chest pains and improve his quality if life. I have diagnosed Mr. Lincoln as follows: Disordered eating pattern (NB-1.5) related to stress from job and recent diagnosis of Marfans Syndrome as evidenced by fatigue and increased frequency of angina pectoris. Mr. Lincolns current weight is 171 lbs, giving him a BMI of 20.8. Although this is within the normal limit, Mr. Lincoln has reported weight fluctuations over the past 5 years, since he was first elected president. He also has struggled with bouts of depression since the deaths of his 2 sons, and is so fatigued that he does not have much time or energy for physical activity. I then proceeded to talk to Mr. Lincoln about his weight and BMI, and explain that although he was in a normal range, his weight fluctuations have been stressful on his body. I explained to him that he could be at risk for a heart attack or other heart complications, including worsening and increased frequency of his chest pains, because of his current lifestyle and eating habits. I then proceeded to educate him on some dietary changes that could help reduce his chest pains, and lessen the strain on his heart. I told him that eating a well balanced diet high in fruits, vegetables, whole grains, omega-3s, and low

Case Study

Katherine Podgwaite

fat dairy could help ease his condition. I also encouraged him to limit saturated fats, sodium, sugary foods, and alcohol consumption, which will also help improve his condition. Finally, I asked if he could foresee himself having time to exercise, and helped him come up with a solution to schedule his meetings in different rooms across the White House for a start, so that he would have to walk to attend them. Intervention Since Mr. Lincoln has refused medication, the goal of this intervention is to regularize his eating pattern and reduce the stress on his heart through dietary changes and small amounts of exercise. With the demands of his job, Mr. Lincoln is a busy man, but has agreed to meet with me once every two weeks for the first two months, and then once every month afterwards. He will also be attending 3 family therapy sessions, which will be conducted by a psychologist, with myself in attendance to take notes and review his dietary changes and progress. I would like to see Mr. Lincoln achieve the overall goal of eating 3 full meals a day, accompanied by 3-4 snacks in between or after meals. Additionally, I would like him to consume 5 fruits and vegetable servings per day, 2 servings of whole grains per day, 2 servings of low fat dairy per day, and 2 servings of fish per week. For now, Mr. Lincoln is not quite ready to make some of these changes, but has agreed to try to eat more full meals with more fruits and vegetables and less sodium. I instructed him in making a list identifying some of his favorite fruits and vegetables and how he can incorporate them into his diet. We also set up times at 10 am and 3 pm where Mr. Lincoln will consume either a fruit, low fat yogurt, or a whole grain snack. Mr. Lincoln will keep a food diary to the best of his ability. We will use our meeting times to evaluate how theses changes have been working for him, and whether he is ready to continue to make more dietary changes. If Mr. Lincoln is not compliant with this plan of action, then I intend to reassess and work together with Mr. Lincoln to come up with a new goals tailored to cope with barriers he may have had in the past. I will be encouraging and reassuring Mr. Lincoln in his progress and goals throughout the meetings. Progress and Follow-Up Over the past 4 months, Mr. Lincoln has made some progress in meeting his goals, although the progress is very slow. He has managed to consume 2 full meals a day this past month, but still continues to work through his meals consistently. Although family has given him great support throughout his lifestyle changes, Mr. Lincoln feels he did not get much out of the family therapy sessions. He still remains distant and unwilling to make certain changes, as he always considers work his number one priority. However, he has increased his fruit and vegetable intake to 2 servings of each per day as well as been consistent with consuming one serving of fruit a day between breakfast and lunch. His sodium intake has not changed. Mr. Lincoln finds it difficult to control his salt intake, and is unwilling to reassess and make changes. He has also not incorporated exercise into his daily regimen. His chest pains are less frequent, but just as severe as before medical nutrition therapy. He feels confident in the progress that he has made, and is proud of the dietary changes he has made. He seems uninterested in continuing to make any more changes, with the exception of increasing his intake of fruits and vegetables to 3 servings of each per day. However, we

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Katherine Podgwaite

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have agreed that he should walk for 15 minutes per day with his family after lunch over the next 4 weeks. I have continued to encourage Mr. Lincoln in his progress and have given him my contact information if he has any questions or concerns. References 1. Ehrlich, Steven D. "Angina." University of Maryland Medical Center. 15 Dec. 2011. Web. 20 Nov. 2013. http://umm.edu/health/medical/altmed/condition/angina 2. Haldeman-Englert, Chad. "Marfan Syndrome." U.S National Library of Medicine. U.S. National Library of Medicine, 30 Apr. 2012. Web. 18 Nov. 2013. http://www.nlm.nih.gov/medlineplus/ency/article/000418.htm 3. "Accommodation Ideas for Marfan Syndrome." Marfan Syndrome. Job Accommodation Network. Web. 20 Nov. 2013. http://askjan.org/soar/other/marfan.html 4. "Marfan Syndrome." Fast Facts about. Web. 18 Nov. 2013. http://www.niams.nih.gov/Health_Info/Marfan_Syndrome/marfan_syndrome_ff.asp 5. "The Health Belief Model." Behavioral Change Models. Boston University School of Public Health, 22 Jan. 2013. Web. 20 Nov. 2013. http://sphweb.bumc.bu.edu/otlt/MPHModules/SB/SB721-Models/SB721-Models2.html 6. Bustamante, Lisa, Debbie Howe-Tennant, and Christina Ramo. "The Behavioral Approach." SUNY Cortland. 1996. Web. 18 Nov. 2013. http://web.cortland.edu/andersmd/beh/behavior.html 7. "Nutrition Care Manual." University of Connecticut. Academy of Nutrition and Dietetics, 2013. Web. 20 Nov. 2013. http://nutritioncaremanual.org/