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Case Study #9
Hypertension in a middle-aged man Medical Nutrition Therapy (DIE 3213) Emily Rose Greco, BS November 14, 2013

1. Define hypertension, suggest how his high blood pressure would be classified, and discuss how his hypertension affects his risk for future health problems. (3 points) Hypertension is persistently high arterial blood pressure (the force exerted per unit area on the walls of arteries) and can be defined as systolic blood pressure (contraction phase of cardiac cycle) 120 mm Hg or higher, and the diastolic blood pressure (relaxation phase of cardiac cycle) 80 mm Hg or higher. Stage 1 Hypertension is between 140-159/90 to 99 mm Hg which is what stage this client is in. Any level of elevated blood pressure is associated with increased cardiovascular and renal disease, so normalization of this measure is crucial for any and all stages of hypertension.1 Untreated HTN (hypertension) leads to heart failure, end stage renal disease, and peripheral vascular diseases. It is called the silent killer due to the fact that it can go unnoticed or remain asymptomatic for many years and then cause a stroke or heart attack.1 His HTN would be classified as essential hypertension (145/92) because it is of unknown cause and is not due to another known disease. Implications for essential hypertension include poor diet, smoking, physical inactivity, family history, stress, vascular inflammation, and obesity.1 2. What is his IBW, %IBW, and BMI? Estimate his caloric requirements. Show your work. (3 points) IBW: Hamwi equation: 106 lb + (6 x 9) = 160 lbs 1 %IBW: (Actual/135) x 100 = 234/135 x 100 = 173.33% BMI: (kg/h2) = 106.36kg/(1.7526m)2 = 34.63 1 Caloric requirements:
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Harris-Benedict equation: 88.362 + (13.397 x 106.36) + (4.799 x 175.26 cm) (5.677 x 60) 88.362 + 1424.905 + 841.07 340.62 = 2013.7 x PAL 1.5 (low active) = 3020 cal/d1 800 cal/d for weight loss = 2,220 cal/d A caloric deficit of 500-1000 kcal daily should be used for weight loss.1 I gave him a PAL value of 1.5 due to the fact that he exercises 20 min a few days per week and is considered a workaholic arising at 4:30 am and working until 10 or 11 pm. An 800 cal deficit is sufficient for gradual weight loss in this client.1 3. Explain the DASH diet. What levels of saturated fat, cholesterol, fiber, sodium, potassium, calcium, and magnesium are included? What would be an expected change in his blood pressure and blood lipids if he follows the DASH diet? (3 points) The DASH diet involves incorporating foods high in calcium, potassium, and magnesium (not just the traditional low-sodium diet). When these minerals are combined they help to lower blood pressure. The diet emphasizes eating whole grains, fat free or low fat dairy products, nuts, fish, fruits, and vegetables so it is high in fiber and low in fat.1 It limits the amount of red meat, sweets, added sugar, and beverages high in sugar. For a 2000 calorie diet levels of particular nutrients in the diet should consist of saturated fat making up no

more than 6% of the calories, only 150 mg cholesterol, 30 g of fiber, no more than 2300 mg of sodium (1500 mg is even better), 4700 mg of potassium, 1250 mg of calcium, and 500 mg of magnesium.2,4 If he were to follow this diet (especially the 1500 mg of sodium version) he would see a dramatic decrease in his high blood pressure and decrease in blood lipids as well.4 If this diet is followed according to calorie needs, a 20 lb weight loss can result in a lowered systolic blood pressure and even less than 10% weight loss can have a sustained effect on blood pressure.2 4. Analyze his diet using MyPlate Tracker. How many kcals is he currently consuming, and how does this compare to his energy needs? How does his usual diet compare to the DASH recommendations? (3 points) He is consuming approximately 2400 calories per day which exceeds his calorie needs and would result in weight gain. His usual diet is extremely high in sodium, cholesterol, and saturated fat and very low in potassium, magnesium, unsaturated fats, and fiber. This way of eating is completely opposite of the DASH diet which emphasizes low intake of sodium, saturated fat, and cholesterol and increased levels of potassium, fiber, unsaturated fats, and magnesium. He is consuming almost enough calcium, however it is about 30-50 mg lower than the 1250 mg recommended for the DASH diet.7,8 5. What type of medication is he on for his blood pressure? Does it have any food drug interactions? (3 points) He is on a thiazide diuretic called Hydrochlorothiazide. This class of diuretics increases the excretion of potassium and magnesium but reduces the excretion of calcium by enhancing renal resorption of calcium. If calcium supplements are taken this could result in hypercalcemia.1 Caffeine also acts as a diuretic in the body so this additional substance could be promoting even further excretion (he drinks a lot of caffeinated coffee 3 large cups per day). Taking potassium supplements and/or consuming increased amounts of potassium-rich foods are recommended.5 6. Go to http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm and enter his age, race, gender, and creatinine level (check yes for traceable to IDMS). This calculates an estimated glomerular filtration rate (GFR), which is a measure of kidney function. What is his estimated GFR (MDRD GFR in mL/min/1.73 m2)? If these readings persisted for at least three months, what would it suggest about the effects of hypertension on his kidneys? (3 points) His estimated GFR is 62. If this level persisted for at least three months it could be indicative of early kidney disease. If protein were found persistently in the urine this would suggest kidney damage and further indication for early kidney disease because proteinuria is the primary marker of kidney damage.6 If this level were to drop lower than 60 and persist for more than 3 months, this would indicate chronic kidney disease. Estimation of progression and careful monitoring would be of utmost importance.2

7. Identify an appropriate nutrition diagnosis and write a PES statement. (3 points) Food and nutrition knowledge deficit related to excessive intake of fats and salt and limited intake of fruits, vegetables, fiber, fish, whole grains and nuts as evidenced by blood pressure of 145/92, BMI of 34.63, 238 mg/dL total cholesterol, 174 mg/dL LDL cholesterol, and 37 mg/dL HDL cholesterol.1,3 8. Suggest specific modifications of diet and lifestyle (interventions) that might lower this clients blood pressure. (3 points) Interventions that may help lower this clients blood pressure would be losing weight first and foremost (by incorporating DASH diet and reducing calories in his diet)2. Other interventions include: Increase physical activity to 30 min per day most days of the week (physical activity of 30 min per day decreases blood pressure by 4-9 mm Hg.)2 Increase intake of fruits, vegetables, whole grains, fat free dairy, fish, and nuts1, 4 Suggesting potassium and magnesium rich foods (due to his medication increasing the excretion of the two nutrients)1,4 Suggest using salt substitutes like Mrs. Dash4 Increase intake of water and reduce intake of caffeinated beverages1 If water seems unappealing add fruit to the water and let it sit over night in the fridge to add some flavor Limit alcohol consumption to two drinks per day (12 oz beer, 5 oz wine, 1.5 oz 80 proof distilled spirits).2 Suggest keeping a food and physical activity diary that also includes daily weigh-ins and blood pressure checks. Make sure the client has a blood pressure machine and if not suggest buying one at a local drug store (if not able to purchase, use in-store blood pressure monitors or if he belongs to a gym ask employees if they have a blood pressure machine he is able use).1 Specific modifications to the diet he provided me: o Eat whole wheat toast rather than white toast1,4 o Eat low fat and reduced sodium cheese1,4 o Cook with margarine, olive oil, or canola oil rather than butter4 o Avoid or reduce consumption of processed foods especially deli meat4 o Replace half and half creamer with fat free milk1,4 o Instead of steak try lean chicken or fish1,4 o Rather than French fries try a baked sweet potato with some margarine and cinnamon4 o Consume fruit and/or vegetables with each meal of the day4 o Use low-fat dressing on salads and unsalted nuts instead of crumbled bacon4 o For the snack instead of coffee to increase energy try almonds, trail mix containing nuts or dried fruit, carrots and hummus, unsalted popcorn, or decaffeinated, unsweetened iced tea4

o Instead of regular premium ice cream for dessert try reduced or low fat ice cream, frozen yogurt with some fruit and nuts, or low calorie/sugar free gelatin4 9. What are your overall goals for this client, and how would you monitor the results or outcomes of your interventions? (3 points) My goals for this client include losing between 12-15 lbs in three months, increase physical activity, adherence to the DASH diet, increase GFR, decrease blood pressure and total cholesterol, and improve LDL/HDL ratio. I would monitor the results of the interventions by having him keep a food and physical activity diary that includes daily weigh-ins and blood pressure checks. I would also follow up with labs every three months to check his total cholesterol, LDL/HDL ratio, and creatinine (in order to monitor the GFR and in turn kidney function).1,2 10. Write a note in ADIME format that summarizes your assessment. (3 points) Assessment: Client seeking suggestions on ways to lower his blood pressure without taking additional antihypertensive medication. 60 yo male Dx: Stage 1 Essential Hypertension Ht. 59 Wt. 234# Labs: Alb 4.2 g/dL Creatinine 1.2 mg/dL Total cholesterol 238 mg/dL LDL 174 mg/dL HDL 37 mg/dL EER: 2,220 kcal/d

Diagnosis: Food and nutrition knowledge deficit related to excessive intake of fats and salt and limited intake of fruits, vegetables, fiber, fish, whole grains and nuts as evidenced by blood pressure of 145/92, BMI of 34.63, 238 mg/dL total cholesterol, 174 mg/dL LDL cholesterol, and 37 mg/dL HDL cholesterol. Intervention: 1. Recommend DASH diet to lose weight (12-15 lbs in 3 months) and help with Hypertension. Give handout and sample diet plan. 2. Recommend increasing physical activity to 30 min most days of the week.

3. Suggest keeping a food and physical activity diary (or utilize MyPlate Supertracker online) and also include record of daily weigh-ins and blood pressure checks. 4. Recommend not adding salt to foods and suggesting alternatives like pepper and Mrs. Dash/herb seasoning. 5. Recommend potassium and magnesium rich foods. 6. Recommend limiting alcohol intake to no more than two drinks per day. Monitoring/Evaluation: 1. Client will state understanding of weight loss being of utmost importance to help with Hypertension. 2. Creatinine, total cholesterol, LDL and HDL levels will be checked every three months. 3. Client will state adherence to DASH diet and physical activity increase. 4. Client will bring logs/diary to go over with me for the next session. Signature: Emily Greco, BS
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11. Plan a 1800 kcalorie diet with specific menu ideas, variety, for seven days using DASH and reasonable portions. Day 1: B: c Oatmeal w/ cinnamon c whole strawberries 1 c skim milk L: 2 c lettuce with one cherry tomato and 1 tbsp chopped carrots and 2 tbsp reduced calorie ranch dressing and 1 oz unsalted, roasted almonds 1 Veggie sub sandwich 8 oz bottle of water D: 1 fillet baked tilapia (seasoned with herbs, no salt) 2 cups raw spinach with 2 tablespoons of Italian dressing cup brown rice (seasoned with herbs, no salt) and cup pineapple chunks mixed in 1 100% whole wheat dinner roll 1 large sweet potato with 1 tablespoon of margarine and cinnamon 8 oz bottle of water Snacks: 1 clementine 8 oz fat free yogurt c fresh raspberries

Day 2: B: c bran cereal 1 banana 1 c skim milk 1 slice whole wheat toast w/ 1 tsp margarine and cinnamon L: Sandwich: c tuna salad, 2 slices whole wheat toast, 1 large leaf romaine lettuce Salad: 2 c spring mix lettuce, 1 tbsp sunflower seeds, c red seedless grapes, cup cucumbers, 2 tbsp Italian dressing 8 oz bottle water D: 3 oz lean chicken seasoned with herbs, no salt 1 c cooked no salt added canned carrots (rinsed) 2 small red potatoes seasoned with herbs, no salt c jasmine rice 1 small apple 1 cup skim milk Snacks: c fat free frozen yogurt with oz almonds Day 3: B: 1 small whole wheat bagel with 1 tbsp peanut butter c blueberries 1 c skim milk L: Steak sandwich: 3 oz lean steak, 2 slices whole wheat bread, 1 slice reduced fat swiss cheese, 1 large romaine leaf, 2 slices tomato, 2 slices avocado 1 c honeydew chunks 1 c steamed assorted vegetables carrots, broccoli, snow peas, green and red peppers (seasoned with herbs, no salt) 8 oz water bottle D: 1 c whole wheat angel hair pasta with 1 tbsp olive oil, tbsp garlic powder, c reduced sodium kidney beans (rinsed), cup sauted spinach (seasoned with herbs, no salt), cup sauted mushrooms (seasoned with herbs, no salt), cup sauted onions (seasoned with herbs, no salt) 1 c skim milk

Snacks: c dried apricots c walnuts Day 4: B: 2 egg whites with c spinach and c shredded reduced fat cheddar cheese (seasoned with pepper and herbs) .5 c hashed-browns 1 peach 1 slice whole wheat bread, 1 tsp margarine with cinnamon 1 c skim milk L: Veggie burger: 1 whole wheat bun, 1 tsp ketchup, 1 tsp mustard, 1 large romaine leaf, 2 slices of onions c baby carrots 2 tbsp hummus 1 small apple 8 oz bottle of water D: 1 c cantaloupe chunks Stir fry: 1 c wild rice, 1 oz grilled chicken, 2 c stir fry vegetables (made with low sodium soy sauce) 1 c skim milk Snacks: 2 cinnamon graham crackers with 1 tbsp peanut butter c cashews Day 5: B: c oats & almonds cereal c skim milk 1 cup orange juice L: Bell pepper stuffed with c brown rice, c onions, oz unsalted slivered almonds, 3 oz reduced fat cheddar cheese (seasoned with herbs, no salt) c papaya chunks 1 c skim milk D: 3 oz turkey meatloaf

1 c collard greens sauteed with 1 tsp canola oil and seasoned with pepper and garlic powder c blackberries 1 c barley 8 oz water bottle Snacks: 2 tbsp almond butter 10 whole wheat crackers 1 apple Day 6: B: 1 c cream of wheat 1 kiwi 1 c skim milk 1 small biscuit with avocado L: c cooked green beans c cooked asparagus c cooked broccoli 1 c barley 5 oz baked mahimahi 8 oz water bottle D: 1 sweet potato 1 c skim milk c cooked cauliflower Quinoa salad: 1 c quinoa, c black beans, c pineapple cooked, 2 tbsp pecans, 3 oz chicken breast cooked Snacks: 6 oz Yoplait yogurt with 2 tbsp pistachios 6 oz prepared cherry gelatin Day 7: B: c grits 1 c grape juice 1 slice whole wheat bread with 1 tbsp natural peanut butter L: 2 c low sodium tomato soup 1 c brown rice

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10 watermelon balls Salad: 1 c spinach with 2 tbsp walnuts, 1 tbsp low calorie Italian dressing 1 c skim milk D: 4 oz cooked turkey breast 2 tbsp cranberry sauce 1 slice of whole wheat bread Salad: 2 c spring mix lettuce with 2 tbsp Italian dressing, 2 tbsp sunflower seeds, c red grapes 1 c skim milk Snacks: 1 c frozen fat free vanilla yogurt
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References 1. Mahan LK, Escott-Stump S, Raymond JL. In: Alexopoulos Y, Frazier DM, eds. Krauses Food and the Nutrition Care Process Thirteenth Edition. St. Louis, MO: Elsevier Saunders; 2012: 24-26, 216, 474-477, 758. 2. Nelms MN, Sucher K, Lacey K, et al. In: Cossio Y, Williams P, Feldman E, et al. Nutrition Therapy and Pathophysiology Second Edition. Belmont CA: Wadsworth Cengage Learning; 2011: 111, 526. 3. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutriton Care Process, 4 th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013. 4. U.S. Department of Health and Human Services (DHHS), National Institutes of Health (NIH), and National Heart, Lung, and Blood Institute (NHLBI). Your Guide to Lowering Your Blood Pressure With DASH. NIH Publication No. 06-4082. Bethesda, MD: National Institutes of Health (revised 2006). Accessed November 10, 2013, from http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf. 5. Medline Plus. Hydrochlorothiazide. Bethesda, MD: National Library of Medicine (NLM); November 18, 2010. Accessed November 10, 201, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682571.html. 6. National Kidney Foundation. Frequently Asked Questions about GFR Estimates. New York, NY: National Kidney Foundation; 2010. Accessed November 10, 2013, from http://www.kidney.org/professionals/kls/pdf/12-10-4004_KBB_FAQs_AboutGFR1.pdf. 7. Eatracker.ca Web Site. www.eatracker.ca. Accessed November 13, 2013. 8. Supertracker USDA website. https://www.supertracker.usda.gov/. Accessed November 14, 2013.