Kimberly Scannevin NTR 504 Case 9: Hypertension Question Answers: 1.

Hypertension can be defined as persistently high arterial blood pressure. The systolic blood pressure during the contraction phase of the cardiac cycle must be 120mm Hg or greater, and diastolic blood pressure during the relaxation phase of the cardiac cycle must be 80 mm Hg or greater (Mahan, Escott-Stump & Raymond, 2012, p. 758). Most other sources state that hypertension is 140/90 mm Hg (this case study book supports this number). The patients blood pressure, at 145/92 mm Hg, would be classified as Stage 1 hypertension. The patients future health problem risk is increased by having hypertension. Future health risks associated with high blood pressure include: organ damage, stroke, heart enlargement, heart failure (the heart must increase its efforts to pump blood throughout the body), retinopathy and chronic kidney disease (Mahan, Escott-Stump & Raymond, 2012, p. 758-761). 2. His ideal body weight: 59 = 106 lbs. + 54 lbs. = 160 lbs. %IBW = actual weight/IBW x 100 = 234 lbs./160 lbs. x 100 = 146% BMI = weight (kg)/height (m2) Weight = 234 lbs./2.2 = 106.4 kg Height = 69 x 0.0254 = 1.75 m m2 = 3.06 BMI = 106.4 kg/3.06 m2 = 34.8 Caloric Requirements using Mifflin-St. Jeor: [10 (106.4 kg) + 6.25 (175.26 cm) -5 (60) + 5] x PA = [1064 + 1095.38 -300 +5] x 1.375 = 2564 calories 3. The DASH diet is a way of eating that one can follow to lower systolic blood pressure (and high blood pressure in general). This is a low-fat diet (low in total and saturated fat), which is high in fiber, that emphasizes fruits and vegetables, non-fat dairy and allows some lean meats and nuts. Whole grains, fish and poultry are included as well. Items to reduce include sweets, added sugars, sugar-sweetened beverages and lean red meat. The diet is low in cholesterol as

well, and emphasizes calcium, potassium, and magnesium. There are two levels of sodium consumption; 2,300 mg and 1, 500 mg per day. It is used for preventing and treating hypertension and pre-hypertension. Nuts, seeds and legumes inclusion, depending on calories, should be to one serving a day. Limited fats and oils, depending on calories, for 2-4 servings per day. Non-fat or low-fat milk, depending on calories, should be 2-4 servings per day. Grains, depending on calories, should be 7-13 servings a day. Vegetables, depending on calories, should be 4-6 servings per day. Fruits and Juices, depending on calories, should be 4-6 servings per day. Meats, poultry and fish, depending on calories, should be 2-3 serving per day. Sweets, depending on calories, should be 5 per week up to two per day. (Mahan, Escott-Stump & Raymond, 2012, p. 1108). Levels of the following are included (2,100 calorie diet): Saturated Fat 6% of calories Cholesterol 150 mg Fiber 30 g Sodium 2,300 mg or 1,500 mg if patient already has high blood pressure Potassium 4,700 mg Calcium 1,250 mg Magnesium 500 mg If the patient follows the DASH diet, his blood pressure and blood lipid levels should decrease (http://www.nhlbi.nih.gov/health/health-topics/topics/dash/). 4. My Plate analysis is attached after the questions. His calorie level is 2528 calories according to the SuperTracker. To lose weight, he should aim for 500 calories less than this; around 2, 000 calories. If you go by the Mifflin-St. Jeor calculation for calories, he should aim for around 2,500 calories to remain at his current weight (which of course he should try to lose weight). He currently does consume the appropriate calories to maintain his energy maintenance needs, but is consuming high fat, empty-nutrient options (and we would like him to eventually get to an optimal weight, as we are not trying to maintain his obesity). Again, his BMI is high, so a suggested 400-500 calorie a day decrease would be optimal. His diet does not follow DASH recommendations at all. He is under his grain requirements, and consumes no whole grains. His fruit and vegetable consumption is very depleted, especially his fruit consumption, which is zero. He is under on dairy, and should add in to one serving more and stick to low-fat, or non-fat dairy (skim milk instead of half and half, low-fat cheese). He eating too much protein; double what is recommended, and should switch to poultry products and baked fish, and stay away from the processed meats and deli meats.

His total and saturated fat levels are double what his levels should be; he needs to switch to light salad dressing, oils and soft margarines instead of butter, full-fat salad dressing and fried foods. His levels of high sodium seasoning, ketchup and mustard are in need of re-evaluation; he needs a condiment makeover. 5. The patient is on hydrochlorothiazide (an antihypertensive diuretic, Thiazide) for his blood pressure. Diuretics lower blood pressure by increasing sodium loss and volume depletion (Mahan, Escott-Stump & Raymond, 2012, p. 765). A food and drug interaction is natural licorice. Alcohol should also be limited. Calcium and or Vitamin D supplementation should be watched; possible risk of hypercalcemia (Pronsky & Crowe, 2012, 166-167). Potassium loss may be increased through urinary excretion, so levels should be watched (Mahan, Escott-Stump & Raymond, 2012, p. 765). 6. As we could not tell his race (I assumed he was not an African American), his CKD-EPI Creatinine was 65, while his MDRD Study Equation was 62. When imputing the values and selecting African American, his values were 76 for CKDEPI Creatinine and 75 for MDRD Study Equation. If these readings persisted for at least three months, the patient may have stage 2 CKD (GFR 60-89), mildly reduced kidney function. Controlling blood pressure is critical in preventing further kidney damage; the patients hypertension may lead to stage 2 CKD (http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/CKDstag es.aspx). 7. Appropriate Nutrition Diagnosis: 1. Undesirable food choices NB-1.7 (10779) (P) related to lack of prior exposure to accurate nutrition-related information (E) as evidenced by food records revealing high fat and high sodium foods at meals, high lab values of total cholesterol at 238 mg/dL, high LDL cholesterol values of 174 mg/dL, high blood pressure of 145/92 mm Hg and a BMI of 34.8 (obese) (S). 2. Excessive mineral intake of sodium (7) NI-5.10.2 (10736) (P) related to lack of knowledge about management of undiagnosed disease state requiring mineral restriction (hypertension and sodium) (E) as evidenced by high blood pressure of 145/92 mm Hg and food records revealing high sodium choices. 8. Specific modifications of diet and lifestyle that might help lower the clients blood pressure would be following the DASH diet mentioned previously, which focuses on low-fat, low-cholesterol, low sodium food intake while increasing fruit and vegetable consumption. The client should switch to whole grain starches, reduced-fat cheeses, switch from half and half to skim milk, reduce processed and red meats in his diet, and add in a variety of fruits and vegetables to meals. Adding salt to meals should be avoided. His moderate exercise should be increased to most days of the week as permitted. The client

should also aim to lose 5-10 % of his body weight over six months to a year to help his health status and reduce his BMI. 9. My overall goals for this client are: reduce blood pressure levels through adopting the DASH diet, watching sodium intake and increasing exercise as permitting by his leg/feet pain. Reducing cholesterol levels to closer to normal lab values would be another goal for this patient; the DASH diet would help improve his food choices and have a great effect on these levels. Hopefully the DASH diet along with an increase in exercise would help reduce the patients BMI to a healthier level, which would be a third goal. Monitoring these results would be to compare his new lab values and blood pressure at future education/monitoring sessions in four to six weeks, checking against the standard values of 120/80 mm Hg for blood pressure and against Total Cholesterol levels of < 200. Food and activity logs should also be suggested and evaluated, and a weigh-in to re-calculate his BMI should occur. 10. S: Patient with some pain in legs and feet, otherwise feels fine. Looking for help on lowering blood pressure without medication. O: Blood Pressure 145/92, Total Cholesterol 238 mg/dL, LDL 174 mg/dL HDL 37 mg/dL. BMI of 34.8. Taking hydrochlorothiazide. A: Patient is a 60 year old hypertensive male taking medication, looking for advice on how to change his lifestyle and eating habits to address the hypertension. P: Nutrition education and reduction of fat and salt in diet suggested. DASH diet suggested. Incremental exercise increase suggested. Continue to monitor labs. Follow up in four weeks to evaluate lab values, food and physical activity logs.

References
Mahan, L.K., Escott-Stump, S. & Raymond, J.L. (2012). Krauses food and the nutrition care process. St. Louis, MO: Elsevier Saunders. National Health, Lung, and Blood Institute. (2012). What Is the DASH Eating Plan? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/dash/ Pronsky, Z. M. & Crowe, S. J. (2012). Food medication interactionsTM: The foremost drug-nutrient interactions resource (17th ed.). Birchrunville, PA: Food-Medication Interactions. The Renal Association. (n.d.). CKD Stages and Hypertension. Retrieved from http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/CKDstages.aspx.