Katie Arlinghaus

KNH 411

Professor Matuzsak

September 10, 2013

Case Study #4 Hypertension and Cardiovascular Disease

I. Understanding the Disease and Pathophysiology

1. Define blood pressure and explain how it is measured.

Blood pressure is the force exerted by the blood on the walls of blood vessels.

During the contraction phase the force is called systolic blood pressure, and during

relaxation phase the force is called diastolic blood pressure. Blood pressure is measured

in mmHg using a sphygmomemeter. and is expressed using the reading for systolic

pressure first (the higher number) and the reading for diastolic pressure second (the lower

number). (Page 286, 288)

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

Mean arterial pressure (MAP) is normally regulated in the body through a

combination of cardiac output and total peripheral resistance. It involves the sympathetic

nervous system, the rennin-angiotensis-aldosterone system, and renal function. (Page

287)

3. What causes essential hypertension?

The cause of essential hypertension (or primary hypertension) is not known.

However, it is thought to be the result of a variety of multiple factors including lifestyle

factors such as diet, lack of exercise, smoking, stress, and obesity. There also appears to

be a genetic component to essential hypertension. Inflammatory responses and individual

differences within the rennin-angiotensin-aldosterone control of blood pressure may also

contribute to the development and progression of hypertension. (Page 288)

4. What are the symptoms of hypertension?

Hypertension typically has no symptoms and often goes undiagnosed, which is how it

got the nickname of the “silent killer.” Hypertenstion can cause congestive heart failure,

kidney failure, myocardial infarction, stroke, or aneurysms. (Page 288)

5. How is hypertension diagnosed?

People with blood pressure greater than or equal to 140/90mmHg are considered to be

hypertensive. However, both systolic and diastolic blood pressures do not need to be

elevated for a person to be diagnosed at hypertensive. Stage 1 hypertension is classified

as a systolic blood pressure between 140-159mmHg or a diastolic blood pressure 90-

99mmHg. Stage 2 hypertension is classified as a systolic blood pressure greater than or

above 160mmHg or a diastolic blood pressure greater than or above 100mmHg. The

diagnosis of hypertension should also include urinalysis, blood glucose, hematocrit and

lipid panel, serum potassium, creatinine, and calcium laboratory tests. (Page 288-289)

6. List the risk factors for developing hypertension.

Risk factors for developing hypertension include excessive sodium intake, low

potassium intake, excessive alcohol intake, lack of exercise, smoking, stress, family

history, age (>55 for men, >65 for women), and obesity (BMI>30kg/m2). (Page 289)
 7. What risk factors does Mrs. Sanders currently have?

According to Mrs. Sanders’s diet recall she has a high sodium intake. She doesn’t

exercise very much (although she did recently begin a walking program and has had

some weight loss success with the program) and used to smoke two packs of cigarettes a

day (fortunately, she quit “cold turkey” a year ago). She also has a family history of

hypertension. Her mother died from MI related to uncontrolled hypertension.

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

the following table of hypertension classifications.

Blood Pressure mm Hg
Category Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Hypertension Stage 1 140-159 or 90-99
Hypertension Stage 2 ≥ 160 or ≥100
(Page 289)

9. How is hypertension treated?

Hypertension is treated through medication, weight reduction, physical activity, and

nutrition therapy. The goal of treatment is to reduce the risk of cardiovascular and renal

disease and to reduce blood pressure to <140/80mmHg. (Page 290)

10. Dr. Thornton indicated in his note that he will “rule out metabolic syndrome.” What

is metabolic syndrome?
 Metabolic syndrome is a constellation of metabolic risk factors for coronary heart

disease including abdominal obesity, insulin resistance, dyslipidemia, hypertension, and

prothrombotic state. (Page 302)

11. What factors found in the medical and social history are pertinent for determining

Mrs. Sander’s CHD risk category?

Mrs. Sanders has a family history of HTN as her mother died from MI due to

uncontrolled HTN. Mrs. Sanders is overweight with a BMI of 25.8 (although has

recently implemented a walking program to lose weight), has high blood pressure at

160/100mmHg. Although she quit “cold turkey” a year ago, Mrs. Sanders used to smoke

two packs a day. From her diet recall, which included items such as canned tomato soup,

saltine crackers, and table salt seasoning, it is evident that Mrs. Sanders has a high intake

of sodium. She also mentions that she finds low sodium food lacking in flavor. Finally,

Mrs. Sanders is African American, which puts her in a higher CHD risk category as HTN

is more prevalent among African Americans. (Page 288)

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

If her hypertension is uncontrolled, Mrs. Sanders may experience congestive heart

failure, kidney failure, myocardial infarction, stroke, or aneurysms. Her vision may be

impaired due to blood vessels bursting or bleeding within her eyes. Hypertension can

also lead to decreased left ventricular ejection fraction, ventricular arrhythmias, or even

sudden cardiac death. (Page 288)

II. Understanding the Nutrition Therapy

13. Breifly describe the DASH eating plan.

 The DASH (Dietary Approaches to Stop Hypertension) eating plan was designed to

not only reduce sodium intake, but also increase potassium, magnesium, calcium, and

fiber intakes within a moderate energy intake. The eating plan was created after a series

of clinical trials in the late 1990s that found that blood pressures were reduced with an

eating plan that was low in saturated fat, cholesterol, total fat, and that emphasized 8-9

servings of fruits and vegetables and three servings of low-fat dairy products. The plan

emphasizes whole-grain products, fish, poultry, nuts, vegetables, and fruits, and limits red

meat, sweets, and sugary beverages. (Page 294-295)

14. Using EAL, describe the association between sodium intake and blood pressure.

According to EAL, there is good evidence that high sodium intakes increase blood

pressure. “Seventeen studies demonstrate the benefit of reducing dietary sodium intake

for lowering blood pressure. A sodium intake of less than 2,300mg per day and further

reduction of sodium intake to 1,600mg may have additional blood pressure-lowering

effects, especially when combined with the DASH dietary pattern.”

(http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250636&highli

ght=sodium&home=1)

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 have been shown to lower blood pressure include

increased physical activity, smoking cessation, weight loss, reduced sodium, saturated

fat, and alcohol intake, and increased calcium, potassium, and fiber intake. (Page 292)

III. Nutrition Assessment

16. What are the health implications of Mrs. Sander’s body mass index (BMI)?

Mrs. Sander’s BMI is 25.8kg/m2, which classifies her as overweight, and increases

her risk for type 2 diabetes, hypertension, and CVD. (Page 300)

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

Using the Mifflin St. Jeor Equation Mrs. Sanders needs 1,343 kcal resting and her

total energy needs are 2,150 kcal.

Women: REE = 10 (weight in kg) + 6.25 (height in cm) – 5(age in years) -161

Weight = 160lbs/2.2lb per kg =72.7kg

Height = 66in*2.54cm per in =167.6cm

REE=10(72.7kg)+6.25(167.6cm)-5(54yr)-161

REE=1,343 kcal

Physical Activity Level=1.6 because she does walk 30min 4-5 times a week.

Total energy needs=REE*PAL

Total energy needs=1,343kcal*1.6

Total energy needs=2,150kcal

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

As a hypertension patient, the nutrients in Mrs. Sanders’s diet that are of major

concern to me include saturated fat, sodium, calcium, potassium, fiber, magnesium, and

cholesterol. According to her diet recall, Mrs. Sanders is consuming excessive amounts

of saturated fat, sodium, and cholesterol. Furthermore, she is not consuming enough

magnesium, potassium, or fiber. (Page 292)

19. From the information gathered within the intake domain, list possible nutrition

problems using the diagnostic terms.

 Possible nutrition diagnoses include:

 Excessive energy intake NI-1.3

 Inappropriate intake of fats NI-5.6.2

 Excessive sodium intake NI-5.10.2 (7)

 Overweight/obesity NC-3.3 (1)

 Food and nutrition-related knowledge deficit NB-1.1

 Physical inactivity NB-2.1

20. Dr. Thornton ordered 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 Implications

Abnormality

Glucose 70-110 mg/dL 92 mg/dL Within normal Above normal value glucose levels
values risks for development of type 2
diabetes may be present.
BUN 8-18 mg/dL 20mg/dL High, above
the normal
range
Creatinine 0.6-1.2 mg/dL 0.9mg/dL Within normal
range
Total 120-199 mg/dL 270 mg/dL Too high, Decrease saturated fat and cholesterol
Cholesterol above normal intake
range
HDL- > 55 mg/dL F 30 mg/dL Low, below Increase fiber intake
cholesterol > 45 mg/dL M normal range
LDL- <130 mg/dL 210 mg/dL High, above Decrease saturated fat and cholesterol
cholesterol normal range intake
Apo A 101-199 mg/dL F 75 mg/dL Low, below Indicates low HDL levels which is
94-178 mg/dL M normal range higher risk for coronary heart disease
Apo B 60-126 mg/dL F 140 mg/dL High, above Indicates high LDL levels which
63-133 mg/dL M normal range increases blood pressure
Triglycerides 35-135 mg/dL F 150 mg/dL Within normal High fat intake
40-160 mg/dL M range
21. Interpret Mrs. Sanders’s risk of CAD based on her lipid profile.

When Mrs. Sanders first came in on 6/25 her total cholesterol was 270 mg/dL which

gave her more than twice the risk of heard disease compared to someone whose

cholesterol is below 200mg/dL. Nine months later Mrs. Sanders is still has a higher risk

with borderline high cholesterol of 210mg/dL. Similarly when she first came in her LDL

levels were very high at 210mg/dL. Nine months later she still has borderline high

levels. Even nine months since her initial visit, however, her HDL levels are still too low

at 38mg/dL, which puts her at major risk of heart disease. Finally, her triglyceride levels

have decreased from borderline high to normal since her first visit. Mrs. Sanders is still

at risk of CAD, however, since her initial visit on 6/25, her risk of CAD has decreased.

(Page 301)

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

person’s risk of CAD?

An apolipoprotein is the protein portion of a lipoprotein. High levels of

apolipoprotein B indicate high levels of LDL, and high levels of apolipoprotein A

indicate high levels of HDL. LDL transport cholesterol and lipids to tissues and serum

LDL levels are the single strongest indicator of CVD risk. Therefore, the higher the level

of apolipoprotein B found, the greater the risk for CAD. Oppositely, since HDL particles

are involved in the reverse cholesterol transport (from tissues to the liver) the more

apolipoprotein A found, the lower the risk for CVD. (Page 301)

23. Indicate the pharmacological differences among the antihypertensive agents listed

below.

Medications Mechanism of Action Nutritional Side Effects and

Contraindications
Diuretics Decreases blood volume Potassium supplements may be
by increasing urinary necessary, avoid natural licorice
output and inhibits renal
sodium and water
reabsorption
Beta-blockers Blocks B-receptors in the Calcium may interfere with absorption
heart to decrease heart
rate and cardiac output
Calcium-channel blockers Affect the movement of Avoid natural licorice, limit caffeine, and
calcium and cause blood avoid or limit alcohol
vessels to relax and
reduce vasoconstriction
ACE inhibitors Vasodilators that reduce Avoid natural licorice, and avoid salt
blood pressure by substitutes
decreasing peripheral
vascular resistance by
interfering with the
production of angiotensin
II from angiotensin I and
inhibiting degradation of
bradykinin
Angiotensin II receptor Interferes with renin- Serum potassium may increase; avoid
blockers angiotensin system salt substitutes
without inhibiting
degradation of bradykinin
Alpha-adrenergic blockers Blocks the vascular Avoid natural licorice
muscle response to
sympathetic stimulation
and reduces stroke
volume.
(Page 291)

24. What are the most common nutritional implications of taking hydrochlorothiazide?

Hydrocholorothiazide inhibit the resorption of sodium, chloride, and potassium in the

loop of Henle of the kidney, which can affect the electrolyte balance. (Page 291)

25. Mrs. Sanders’s physician has decided to prescribe an ACE inhibitor and an

HMGCoA reductase inhibitor (Zocor). What changes can be expected in her lipid profile

as a result of taking these medications?

 As a result of taking these medications Mrs. Sander’s blood pressure can be expected

to decrease. The ACE inhibitors competitively block the enzyme that converts

angiotension I into angiotension II, which results in vasodilation, a decrease in

vasopressin release, and a resulting decrease in blood pressure. The HMGCoA reductase

inhibitor, Zocor, will lower her LDL cholesterol level by slowing down the synthesis of

cholesterol. (Page 292, 217, http://www.ncbi.nlm.nih.gov/books/NBK47273/)

26. How does an ACE inhibitor lower blood pressure?

An ACE inhibitor lowers blood pressure by blocking the enzyme that converts

angiotension I into angiotension II, which results in vasodilation, a decrease in

vasopressin release, and a resulting decrease in blood pressure. Since angiotension I is

not able to convert into angiotension II, the blood vessels dialate and relax, which allows

less resistance in the blood so that there is a lower blood pressure. (Page 292)

27. How does an HMGCoA reductase inhibitor lower serum lipid?

HMGCoA reductase inhibitor lowers serum lipid by inhibiting the production of an

enzyme needed to produce cholesterol. The liver responds by producing extra LDL

receptors which reduce the amount of LDL in the bloodstream, which consequently

lowers blood pressure.

(https://provider.ghc.org/open/caringForOurMembers/patientHealthEducation/conditions

Diseases/statins.pdf)

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

Hypercholesterolemia can be treated through the use of diuretics, aldosterone

antagonists, nitrate, digitalis, fibrinolytic therapy, and positive inotropic drugs. (Page

291)
 29. What are the pertinent drug-nutrient interactions and medical side effects for ACE

inhibitors and HMGCoA reductase inhibitors?

Side effects of ACE inhibitors include hypotension (especially in elderly patients),

worsening renal function, hyperkalemia, dysguesia, dry/non productive cough,

interactions with natural licorice and salt substitutes. Side effects for HMGCoA

reductase inhibitors (also called statins) include interactions with grapefruit, and alcohol.

They should be taken on a low fat and low cholesterol diet and may cause constipation,

stomach pain, nausea, headaches, or memory loss. (Page 291, 217)

30. From the information fathered within the clinical domain, list possible nutrition

problems using diagnostic terms.

 Overweight/obesity NC-3.3 (1)

 Altered nutrition-related laboratory values: High cholesterol of 270mg/dL NC-2.2

31. What are some possible barriers to compliance?

Some possible barriers to compliance include Mrs. Sanders not complying with a low

sodium diet because she feels that the food lacks flavor without the salt, and Bingo night.

It seems that on bingo night Mrs. Sanders forgoes her exercise and diet program. It

would also be helpful for both Mr. and Mrs. Sanders to be on the same page and work

together to be healthy.

IV. Nutrition Diagnosis

32. Select two nutrition problems and complete the PES statement for each.

a. Excessive sodium intake related to frequent consumption of high sodium foods as

evidenced by patient’s 24-hour diet recall and high blood pressure of

160/100mmHg.
 b. High cholesterol related to inappropriate intake of fats as evidenced by patient’s

24-hour diet recall and cholesterol lab results of total cholesterol of 270mg/dL

with high LDL levels of 210mg/dL and low HDL levels of 30 mg/dL.

V. Nutrition Intervention

33. When you ask Mrs. Sanders how much weight she would like to lose, she tells you

should 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?

Using the Hamwi Method, Mrs. Sanders’s ideal weight would be 130lbs.

100lbs for the first 5 feet of ht + 5 lbs for every inch over 5 feet:

100 + 5 (6in over 5 feet) =130lbs

Therefore, 125 is a pretty reasonable weight goal for Mrs. Sanders, although it would

be slightly lower than ideal. I would suggest she have a goal of 130lb as calculated by

the Hamwi Method. (Page 48)

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

Mrs. Sanders should lose this weight gradually so that she will be more likely to keep

the weight off. She could lose 1 to 2 lbs a week and lose the 30lbs in 4-7 months. (Page

264)

35. 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).

a. Lower blood pressure to <120/80mmHg by educating patient on ways to add

flavor to foods without adding salt and implementing the DASH diet with less

than 2300mg salt a day.

 b. Reduce total cholesterol to <200mg/dL, lower LDL level to <130 mg/dL, and

raise HDL level to >55 mg/dL by educating patient on the importance of and how

to implement the DASH diet plan into her daily life.

36. 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?

According to her diet recall, the major sources of sodium in Mrs. Sanders’s diet

include canned tomato soup, saltine crackers, and table salt added to flavor foods. I

would advise her to buy low sodium tomato soup or make her own at home, eat lower-

sodium whole-wheat crackers instead of saltines, and try to add spices and herbs instead

of salt to flavor her foods. The saturated fat and cholesterol in her diet comes from salad

dressing, donuts, added butter, and ice cream. I would advise her to limit her dessert

intake, maybe have either a donut or ice cream in a day instead of both. She could buy

lower fat dressings or oil-based dressings for her salad. She could also try to cook with

oil instead of butter, or try adding nut butter to her oatmeal instead of margarine.

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

appointment?

In three to four weeks I would want to reevaluate her efforts to eat lower sodium

foods and how she is doing with her walking program. I would check her weight and

cholesterol levels. I would also measure her blood pressure. Hopefully her progress will

be positive after she has implemented the diet changes.

38. Evaluate Mrs. Sanders’s labs at six months and then at nine months. Describe the

changes that have occurred.

 Mrs. Sanders’s labs at six and nine months illustrate that she had made progress! Her

HDL has increased and LDL has decreased so that her total cholesterol level has

decreased. Her triglycerides have also decreased. While still not where they need to be,

her lipid profile is showing that she has made progress and that the program is working.

Mrs. Sanders’s BUN, glucose, Bilirubin, and RBC have all also decreased. These results

should help provide encouragement and motivation to help Mrs. Sanders stay with her

program.
References

Academy of Nutrition and Dietetics. (2005). Evidence Analysis Library: What evidence

suggests a relationship between sodium intake and blood pressure in healthy and

hypertensive adults? Retrieved from

http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250636

&highlight=sodium&home=1

Group Health Cooperative. (2011). Statins & ACE Inhibitors. Retrieved from

https://provider.ghc.org/open/caringForOurMembers/patientHealthEducation/con

ditionsDiseases/statins.pdf.

Nelms M, Sucher K, Lacey, K., Habash, D., Roth S. Nutrition Therapy and

Pathophysiology. 2nd ed.Belmonte, CA: Thomson Brooks/Cole, 2010.

Net Industries Science Encyclopedia. (2013). Hypertension-Prognosis. Retrieved from

http://science.jrank.org/pages/3488/Hypertension-Prognosis.html.

Smith MEB, Lee NJ, Haney E, et al. Drug Class Review: HMG-CoA Reductase

Inhibitors (Statins) and Fixed-dose Combination Products Containing a Statin:

Final Report Update 5 [Internet]. Portland (OR): Oregon Health & Science

University; 2009 Nov. Retrieved from:

http://www.ncbi.nlm.nih.gov/books/NBK47273/

Zelman K. (2012). Salt Shockers. Retrieved from

http://www.webmd.com/diet/ss/slideshow-salt-shockers.