CVD Adime w23 Complt 1

Case Study - CVD
CARDIOVASCULAR DISEASE & HYPERTENSION
Patient Hx: Mrs. Wallace was diagnosed 1 year ago with Stage 1 (essential) HTN. She is a 55yo
married African American woman who is not employed outside the home and has 4 grown
children. Treatment so far has focused on non-pharmacological measures. She began a walking
program and lost 10lbs, and has been able to maintain if for the past year. She walks 30mins, 4-
5 times per week. Her doctor gave her a diet sheet that outlined a 2g Na diet, but she has not
met with a dietitian. Mrs. W smoked 2 ppd up until she was diagnosed last year; she no longer
smokes and does not use any form of nicotine. She has no c/o of any symptoms related to HTN.
Mrs. W denies chest pain, SOB, syncope, palpitations, or MI. PMH not significant.
Nutrition Hx: Mrs. W states, “I’ve tried to cut back on salt, but food just doesn’t taste good
without it. I want to control my blood pressure because my mother passed away from a heart
attack and now I’ve been told I have high cholesterol!”
Mrs. W does the majority of grocery shopping and cooking and reports having a “good”
appetite. She usually eats 3 meals/day. On Fridays and Saturdays Mr. & Mrs. W go out to
dinner, often to a pizza parlor, steak house, or the local diner. She tried to follow the 2g Na diet
sheet she was given, but found the foods bland and tasteless and abandoned the effort within a
couple of weeks.
24 hour recall:
Breakfast: 1 c coffee, 1 cup OJ, 1 packet instant oatmeal (plain) with 1 tsp margarine, 2 tsp
brown sugar
Snack: 2 c coffee, 1 glazed donut
Lunch: 1 can Campbell’s tomato bisque soup with 1 c 2% milk, 10 saltines, 1 can diet soda
Dinner: 6 oz baked skinless chicken breast (seasoned with salt, pepper and garlic), 1 large
baked potato with 1 T butter, salt, pepper, 1 c glazed carrots, 1 c dinner salad (lettuce, spinach,
croutons, cucumber, red onions), 2-3 T Ranch dressing, 2 cans of beer, 1 multivitamin/mineral
HS snack: 2 cups popcorn (butter, no salt)
Diet order: 2g Na
Vitals Signs: BP: 150/86 HR: 80 Resp Rate: 15
Ht: 66” Wt: 160lb WC: 36”
MD Notes: Initiation of pharmacologic therapy with thiazide diuretics and reinforcement of
lifestyle modifications to decrease fat and sodium intake. R/O metabolic syndrome. Perform
urinalysis, hematocrit, blood chemistry to include BG, potassium, BUN, Cr, a fasting lipid profile,
TG, calcium, uric acid, chest x-ray, EKG, Nutrition consult, reassess in 1 mo.
FOLLOW-UP NOTES:
Labs: Gluc: 96 mg/dl; TC: 270mg/dl; HDL-C: 30mg/dl; LDL-C: 210mg/dl; Apo-A: 75mg/dl; Apo-B:
140mg/dl; TG: 150mg/dl; all others WNL.
Dx: Hypertensive heart disease, early COPD, dyslipidemia
Rx ordered: Ramipril (Altace); Hydrochlorothiazide; Atorvastatin (Lipitor)
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Questions
1. How is blood pressure regulated in the body? Please describe the mechanisms and
physiological processes. Refer to your textbook for details.
• Blood pressure in the body is primarily regulated by the sympathetic nervous system,
the baroreceptor reflex, and the renin-angiotensin-aldosterone system (RAAS) and
related kidney function (retention of fluid or electrolytes like Na, Cl, K, as a result of
baroreceptor feedback).
• RAAS functions as follows:
o Baroreceptors perceive low blood pressure and start signaling to increase BP.
This causes the liver to release angiotensinogen and the kidneys to release
renin, which interacts with the angiotensinogen to form angiotensin I, which
interacts with ACE released from the lungs to form angiotensin II. Angiotensin
II causes the blood vessels to vasoconstrict and activates the adrenal gland to
release aldosterone which acts on the kidney to cause the reabsorption of NaCl
and water, thus increasing BP.
• The sympathetic nervous system increases heart rate (HR) by simulating the sinoatrial
node and ventricles. Fibers release norepinephrine which increases vasoconstriction and
heart rate. The sympathetic nervous system plays a pivotal role in the long-term
regulation of arterial blood pressure through the ability of the central nervous system to
integrate neurohumoral signals and differentially regulate sympathetic neural input to
specific end organs. In contrast, the parasympathetic nervous system is important in
regulating blood pressure under resting conditions. It prevents any abnormal increase in
blood pressure. If the blood pressure increases due to any reason, it is sensed by the
baroreceptor system. The baroreceptor reflex stimulates the parasympathetic system.
The PSNS causes relaxation of blood vessels, decreasing total peripheral resistance and
heart rate so that BP decreases.
• The Baroreceptor reflex works as such: when blood pressure increases it is sensed by
the baroreceptors which increases baroreceptor activity. This leads to an increase in the
number of afferent impulses toward the cardiovascular center of the brain, which result
s in increased PSNS activity and decreased SNS activity, which decreased cardiac output
and causes vasodilation to reduce blood pressure. Alternatively, where blood pressure
decreases there is decreased baroreceptor activity and a decrease in the number of
afferent impulses toward the cardiovascular center. The Increases SNS activity and
decreases PSNS activity, resulting in an increase in Cardiac output and causing
vasoconstriction to increase blood pressure.
2. What is essential hypertension?
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Essential hypertension is when the hypertension is idiopathic or has no known specific cause
(not due to another medical condition) rather than being due to a primary problem as in
secondary hypertension.
3. What causes essential hypertension?
There can be many causes of essential hypertension including obesity, family history, and
unhealthy diet (diet with excessive sodium intake, low potassium intake, and excessive
alcohol intake). Other lifestyle factors that can contribute to essential hypertension are lack
of exercise, smoking, stress, and obesity. Non-modifiable factors include age over 65 years,
ethnicity (increased risk for black patients, and other non-East Asian POC), and family
history, as well as genetic factors.
4. What are Mrs. W’s modifiable & non-modifiable risk factors for hypertension and CVD?
Modifiable Risk Factors Non-Modifiable Risk Factors

Diet with excessive sodium intake, low Ethnicity – African American Woman
potassium intake, and high alcohol intake
per 24-hr recall. Family hx of CVD (mother passed of MI)
Increased body fat – BMI of 25.8 (> 25 –

qualifying for the overweight classification)
Non-adhereance with 2g Na diet as

recommended by MD.
Age is < 65 yrs old and thus doesn’t qualify
Hx of smoking 2ppd prior to HTN diagnosis
last year
5. Hypertension is classified in stages based on the risk of developing CVD. Complete the
following table of hypertension classifications based on the 2017 ACC/AHA guidelines.
Blood Pressure (mm Hg)
Classification Systolic Diastolic
Normal <120mmHg and < 80mmHg
Elevated Blood
120-129 mmHg or < 80 mmHg
Pressure
Hypertension Stage 1 130-139 mmHg or 80-89 mmHg
Hypertension Stage 2 >/=140 mmHG or >/= 90 mmHg
6. Given these criteria, with what stage of hypertension should Ms. W be diagnosed?
Ms. W has a BP of 150/86 mmHg. Since her systolic blood pressure is > 140 mmHg, she
qualifies for Hypertension Stage 2.
7. How is hypertension treated? (Stages & treatments recommended – refer to JNC-8 on PL)
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Since Ms. W is an adult aged > than 18 years old HTN treatment should be started with
implementing lifestyle modifications like the 2g Na diet she was recommended by the
doctor and ceasing smoking as she has already done. Then a BP goal should be set and BP
lowering medications should be prescribed based on the algorithm presented in JNC 8
Hypertension Guidlien Algorithm. Since Ms. W does not have diabetes or CKD (BG and BUN
and creatinine levels WNL), and she is < 60 years old her BP goal is set at <140/90mmHg.
Since she is Black, initiate thiazide or CCB alone or together. (She is currently on a thiazide
and an ACE inhibitor per MD note). Since this did not get her to her blood pressure goal
(current BP is 150/86mmHg), next steps are to reinforce lifestyle and adherence to
recommendations including continuing smoking cessation, continuing to control BG and
controlling lipids (she is on Lipitor), diet (DASH diet style recommendations, limiting Na and
increasing Ca, K, fiber, moderate alcohol consumption – one drink per day for women,
reducing sodium intake to less than 2000 g/day,)and continuing physical activity with goal
of moderate to vigorous activity 3-4 days a week averaging 40 min per session.
Simultaneously titrate medications to maximum dose and consider adding another
medication. (Strategy is to start one drug, titrate to maximum dose, then add a second,
then titrate that one to max dose if needed. Only start two drugs at the same time if BP
more than 20/10mmHg over goal BP)
https://www.umpquahealth.com/wp-content/uploads/2019/03/jnc-8-hypertension-guideline-
algorithm.pdf
8. The MD indicated in his admitting note that he will “R/O metabolic syndrome.”
a) What is metabolic syndrome?
Metabolic syndrome is a metabolic disorder of multiple etiologies including central adiposity,

insulin resistance, dyslipidemia, and hypertension. The diagnostic criteria include lipid profile
and waist circumference. It increases risk for coronary artery disease.
b) What are the criteria? (Use NCEP or IDF criteria)
According to the NCEP ATP III definition, metabolic syndrome is present if three or more of
the following five criteria are met: waist circumference over 40 inches (men) or 35 inches
(women), blood pressure over 130/85 mmHg, fasting triglyceride (TG) level over 150 mg/dl,
fasting high-density lipoprotein (HDL) cholesterol level less than 40 mg/dl (men) or 50 mg/dl
(women) and fasting blood sugar over 100 mg/dl.
c) What are the risks?
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Risk factors include high blood pressure, high TG, low HDL, abdominal obesity, insulin
resistance and blood clotting, obesity, family hx of metabolic syndrome, and sedentary
lifestyle. Metabolic syndrome is a risk factor for (contributing to the cause of) HTN and
other CVD including stroke and coronary artery disease and type 2 diabetes.
9. Sodium restriction is often suggested as a treatment for HTN. Answer the following
question accordingly.
a) What is the rationale for sodium restriction in treatment of hypertension?
- The goal of HTN treatment is to decrease risk of CVD and CKD and reduce BP to <
120/80 mmHg. Interventions for this include MNT, which is usually the DASH diet, which
includes a sodium restriction. A sodium restriction should help to decrease serum Na
which should decrease fluid retention and overall blood volume, decreasing blood
pressure. Since the goal is to decrease cardiac output and peripheral resistance, this the
decrease of blood volume is beneficial, which is why diuretics are often prescribed for
HTN. In a study on the DASH diet vs the SA diet, reduced daily sodium lowered BP on
either diet and less sodium resulted in greater BP decreases (a reduction of about 1.75 g
sodium per day (4.4 g sodium chloride/day) was associated with a mean reduction in
systolic/diastolic blood pressure of 4.2/2.1 mmHg). Benefits were observed in people
with HTN and without HTN of both sexes and regardless of ethnicity.
b) Why has this been controversial?
There is strong evidence for a causal relationship between salt intake and blood pressure.
Randomized trials demonstrate that salt reduction lowers blood pressure in both individuals
who are hypertensive and those who are normotensive, additively to antihypertensive
treatments. Methodologically robust studies with accurate salt intake assessment have shown
that a lower salt intake is associated with a reduced risk of cardiovascular disease, all-cause
mortality, and other conditions, such as kidney disease, stomach cancer, and osteoporosis.
Multiple complex and interconnected physiological mechanisms are implicated, including fluid
homeostasis, hormonal and inflammatory mechanisms, as well as more novel pathways such as
the immune response and the gut microbiome. High salt intake is a top dietary risk factor.
HOWEVER, There is now consensus that different individuals have different susceptibilities to
blood pressure (BP)-raising effects of salt and this susceptiveness is called as salt sensitivity.
Several renal and extra-renal mechanisms are believed to play a role, including blunted activity
of the renin–angiotensin–aldosterone system (RAAS). Thus, there may be potential benefit so
recognizing and therapeutically addressing that salt sensitive phenotype in humans. In basic
terms, recent research has focused on salt sensitivity in humans and found that some people
are more salt sensitivity than others. Some can excrete excess salt without and increase in BP
while others are more affected, thus decreasing dietary salt may be less important for more salt
tolerant individuals. There is not enough evidence to bring this to patients at this time, as it
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might decrease adherence to low sodium diets, proven to decrease BP. The only other
controversy surrounding low sodium diets is the level of salt restriction that is reasonable for
adherence while still being beneficial (controversial according to pts anyway). This can be
worked through with each individual patient by setting SMART goals to first reduce their Na
intake, then gradually lower it to < 2300 mg/day.
10.The most recent recommendations suggest the therapeutic use of stanol/sterol esters for
CVD.
a) What are stanol esters?

Plant stanol ester is a natural compound which is used as a cholesterol-lowering
ingredient in functional foods and food supplements. Plant stanols or sterols are
cholesterol-like structures in plants that compete with cholesterol for absorption and
thus decrease the absorption of cholesterol. 1-3 g daily is an appropriate intake.
b) What is the rationale for using stanol esters?
Since the structure of stanol esters is similar to that of cholesterol, they compete with
cholesterol for absorption and thus decrease cholesterol absorption and serum
cholesterol.
c) What are good sources of stanol esters (natural or manufactured sources)?
Plant stanols and sterols are found naturally in a range of plant-based foods including vegetable
oils, grain products such as breads and cereals, seeds, nuts, legumes, and fruits and
vegetables. Plant stanol supplements such as Benecol and Promise Activ can also be
purchased and added to the diet.
11. Calculate and interpret/classify Mrs. W’s BMI, IBW, %IBW, UBW, %UBW, and % BW change.
Calculation Value Interpretation*
BMI 160 #/2.2#/kg = 72.73kg, 25.8 (kg/m^2) 25.8 is between 25.00
(kg/m2) and 29.9, so BMI meets
66”*2.54cm/in = 167.64 cm / 100cm/m = 1.6m qualifications for
overweight.
BMI = 72.73kg/(1.6764m^2) = 25. 8
IBW 5’ 6” → 100# + 5(6”) = 130#/2.2#/kg = 59kg 59kg NA

(kg)
%IBW 160#/130# * 100 = 123% 123% 123% > 120% of IBW
indicating obesity
UBW 170#/2.2#/kg = 77.27kg (for last year’s visit) 77.27kg (last NA % wt change
(kg) 160 #/2.2#/kg = 72.73kg year), indicates significance of
72.73kg (since wt change
she has been
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able to
maintain 10 lb
loss over a
year, UBW this
year is 72.73
kg)
%UBW 160#/170# * 100 = 94% UBW – percent wt 94% UBW, percent wt change is 6%
change is 6% wt loss in less than a year and 100% UBW (if in less than a year and
able to keep it off for a year – presume not 10 lb loss is able to keep it off for a
over short enough time period to be significant considered year – presume not over
wt change usual since it short enough time
has been period to be significant
maintained for wt change
a year)
*Indicate not applicable with NA.
12. Calculate Mrs. W’s energy needs. Identify the formula & factors used and your rationale for
the formula & factors chosen.
Female - MSJ: (RMR=(9.99*Wkg) + (6.25Hcm) – (4.92Ayrs) – 161)
AF
AF = 1.2 because PA is walking 30 minutes 4-5 times per week which

Formula & factors
is less than 30 minutes of moderate activity per day so gernal acjtivty
level is sedentary, non-hospital, which is the 1.0-1.4 AF bracket. She
is not completely sedentary and without PA so, 1.2 is appropriate.
Female-MSJ: (RMR=(9.99*72.73kg) + (6.25*167.64 cm) –

(4.92*55yrs) – 161)1.2 = 1611 kcal/day
Calculation & Value
Use of female MSJ because it is standard for a non-critically ill patient

who is afab like Ms. W.
AF 1.2 because PA is walking 30 minutes 4-5 times per week which is
Rationale
less than 30 minutes of moderate activity per day so gernal acjtivty
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13. How many calories per day would you recommend for Mrs. W to lose weight and why?
- In general a recommendation of a deficit of 500 kcal/day is adequate for a 1#/wk loss or 250
kcal/day is sufficient for 0.5 lb/wk wt loss , but in this case wt loss is not a relevant primary
goal for HTN MNT treatment, since pt is only slightly overweight and has maintained a 10 #
wt loss x 1 yr.
14. Calculate the specific recommended intake for Mrs. W for each nutrient based on the TLC
(not DASH) diet nutrient composition guidelines:
Nutrient Recommended Intake/Day
Estimated Energy Needs for (RMR=(9.99*72.73kg) + (6.25*167.64 cm) – (4.92*55yrs) –
Wt Maintenance 161)1.2 = 1611 kcal/day
1#/wk wt loss = 500 kcal/day deficit, so .5#/wk wt loss is
Energy Needs for 0.5 lb/wk
250kcal/day deficit (500/2 = 250). This would be 1611kcal-
Wt Loss
250kcal = 1361kcal/day which is not particularly sustainable
6% kcal (<7%) from saturated fat, 1611*.06 = 96.66 kcal from
Saturated fat (g)
saturated fat/9kcal/g = 10.74 g saturated fat
10% kcal (up to 10 %), 1611*.1 kcal = 161.1kcal/9kal/g = 17.9g
Polyunsaturated fat (g)
polyunsaturated fat
20% kcal (up to 20% kcal) 1611*.2 = 322.2/9kcal/g = 35.8 g
Monounsaturated fat (g)
monounsaturated fat.
100-(18+55) = 27% kcal from fat (within 25-35% kcal from fat);
Total fat (g) 1611kca; *0.27 = 434.97 kcal from fat /9kcal/g = 48.33 g FAT
total
Cholesterol (mg) <200 mg/day
55% CHO (within 50-60% kcal from CHO)
CHO (g)
1611*0.5 = 805.5 kcal from CHO/4 kcal/g = 201.375g CHO
Fiber (g) Increase 5-10 g per day
Protein factor 1g/kg for adult maintainaence out side of acute
conditions, range for acute conditosn is 0.8-1.0 g/kg,
Protein (g)
72.73kg*1g/kg = 72.73g PRO* 4 g/kcal = 291 kcal from PRO,
291kcal/1611kcal* 100 = 18% (within the 15-25% recommened
by the TLC diet)
Sodium (mg) < 2,300 mg/day (< 2000mg/day per 2g Na diet per MD)
Stanol Esters (g) Add up to 2 g per day
15. The MD ordered an EKG and the following labs. In the following table, outline the indication
for these tests (tests provide information related to a disease or condition).
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Parameter Normal Pt’s Indication/R MNT Recommendation
Value Valu eason for
e Abnormality
WNL, no Continue to regulate BG through low/decreased
indication of simple CHO consumption but no specific dietary
Glucose
70-110 96 insulin interventions at this time
(mg/dL)
resistiance or
T2DM
WNL, no Maintain adequate fluid intake, no other MNT at
indication of this time
BUN (mg/dL) 8-20 20
CKD or
dehydration
Creatinine indication of this time
0.6-1.2 0.9
(mg/dL) CKD or
dehydration
High 270 > Decrease consumption of saturated fat (< 5-6% of
199, kcal) and cholesterol, and trans-fat (< 1% of kcal).
indication of Replace staruated and trans fats with mono- and
Total chol dyslipidemia polyunsaturated fats. Sources of monounsaturated
120-199 270
(mg/dL) fats are cold water fatty fish like salmon, srdiens,
herring, mackerel, sources of polynunsaturated ftas
like omge-6 are vegetable oils, corn, safflower,
sunflower oils.
Low 30 < 55, Decrease consumption of saturated fat (< 5-6% of
indication of kcal) and cholesterol, and trans-fat (< 1% of kcal).
dyslipidemia Replace staruated and trans fats with mono- and
HDL-chol >55 (F) polyunsaturated fats. Sources of monounsaturated
30
(mg/dL) >45 (M) fats are cold water fatty fish like salmon, srdiens,
sunflower oils.
indication of Replace staruated and trans fats with mono- and
LDL-chol dyslipidemia polyunsaturated fats. Sources of monounsaturated
<130 210
(mg/dL) fats are cold water fatty fish like salmon, srdiens,
sunflower oils.
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e Abnormality
Low 75 < Decrease consumption of saturated fat (< 5-6% of
101-199 indication of Replace staruated and trans fats with mono- and
Apo A (F) dyslipidemia polyunsaturated fats. Sources of monounsaturated
75
(mg/dL) 94-178 and fats are cold water fatty fish like salmon, srdiens,
(M) increased herring, mackerel, sources of polynunsaturated ftas
risk of CVD like omge-6 are vegetable oils, corn, safflower,
sunflower oils.
Apo B (F) dsylipidemia polyunsaturated fats. Sources of monounsaturated
140
sunflower oils.
Triglycerides (F) dyslipidemia polyunsaturated fats. Sources of monounsaturated
150
sunflower oils.
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16. Indicate the pharmacological differences among the antihypertensive agents listed below.
Medications Mechanism of Action Nutritional Implications
Diuretics Loop and thiazide diuretics Loop and thiazide diuretics are
decrease sodium reabsorption in potassium wasting, requiring
the nephron allowing increased increased intake of potassium via
increased fruit and vegetable intake.
urinary sodium and water losses.
Increased K, increased Mg (possible
Thiazides inhibit the Na/CL supplementation) and potential
cotransporter in the renal distal decreased kcal and decrease Na
convoluted tubule to do so. consumption might be called for.
Potassium sparing diuretics like
sprionlactone which is a specific Potassium sparing diuretics have a
pharmacologic antagonist of potential to cause hyperkalemia –
hold K supplementation and
aldosterone, acting primarily
decrease vegetable consumption
through competitive binding of temporarily till hyperkalemia is
receptors at the aldosterone- resolved.
dependent sodium-potassium
exchange site in the distal
convoluted renal tubule. In general
these diuretic sprevent Na-K
exchange and inhibit aldosterone
to decrease BP via inhibiting
vascoconstriction. It also increases
water loss in urine.
Beta-blockers Beta blockers, also called beta People taking beta blockers may
adrenergic blocking agents, block experience significant increases in
the release of the stress hormones blood levels of potassium, though it
adrenaline and noradrenaline in is unknown whether
certain parts of the body. This supplementation with potassium
results in a slowing of the heart might enhance this effect. People
rate and reduces the force at which taking beta-blockers should
blood is pumped around your therefore avoid taking potassium
body, and thus reduces cardiac supplements, or eating large
output quantities of high-potassium foods,
such as fruit (e.g., bananas), unless
directed to do so by their doctor.
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Calcium-channel Calcium channel blockers are
blockers medicines used to lower blood Calcium channel blockers are
pressure. They stop calcium from prescribed for high blood pressure
entering the cells of the heart and and are also affected by grapefruit
arteries. Calcium causes the heart juice. Grapefruit juice changes the
and arteries to squeeze more way this drug breaks down in the
strongly. By blocking calcium, body and may cause overly high
calcium channel blockers allow levels of the drug in the blood,
blood vessels to relax and open, raising the risk of side effects. Avoid
reducing vasoconstriction grapefruit juice.
ACE inhibitors Angiotensin-converting enzyme Insure adequate fluid
(ACE) inhibitors are medicines that intake/hydration. Decreased sodium
help relax the veins and arteries to and kcal might be recommended.
lower blood pressure. ACE Avoid salt substitutions. Caution
inhibitors prevent an enzyme in the with K and Mg supplementation.
body from making angiotensin 2, a Taking potassium supplements,
substance that causes potassium-containing salt
vasoconstriction This narrowing substitutes (No Salt, Morton Salt
can cause high blood pressure and Substitute, and others), or large
forces the heart to work harder amounts of high-potassium foods
(such as bananas and other fruit) at
the same time as taking ACE
inhibitors could cause life-
threatening problems. Alcohol could
exacerbate hypotension.
Angiotensin II ARBs work by blocking receptors
receptor blockers that the hormone acts on, Since ARBs may increase blood levels
specifically AT1 receptors, which of potassium, the use of potassium
are found in the heart, blood supplements, salt substitutes (which
vessels and kidneys. Blocking the often contain potassium), or other
action of angiotensin II helps drugs that increase potassium may
decrease vasoconstriction and to result in excessive blood potassium
lower blood pressure and prevent levels and cardiac arrhythmias
damage to the heart and kidneys
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Alpha-adrenergic Alpha blockers lower blood
blockers pressure by keeping a hormone Some alpha-blockers may also
called norepinephrine from interact with alcohol, citrus juices, or
tightening the muscles in the walls grapefruit jucies. Avoid excessive
of smaller arteries and veins. As a alcohol consumption, avoid
result, the blood vessels remain grapefruit, and decrease citrus juice
open and relaxed (vasodilation). consumption.
17. Mrs. W tells you, that a lot of her friends have lost weight on the Keto and the Paleo diets.
She would like to know if one of these diets would be for her to follow to try get the extra
weight off. What can you tell Mrs. W about the typical high-protein and high fat, low-
carbohydrate approaches to weight loss?
Typical high-protein and High-fat, low-carbohydrate diets like the Keto and Paleo diets are
restrictive diets that are not sustainable. The way they, like all diets in popular media, are
portrayed are as temporary dietary changes. Even if wt was lost on these diets, once the
carbohydrate restriction is removed the weight would be regained. In addition, the wt lost
would likely be lean muscle mass, and the wt regained would like be adipose tissue,
decreasing metabolic rate and overall metabolism and decreasing energy need overall
which is not idea for the patient. Also, restrictive diets like these can trigger the binge-and
restrict cycle in which patients who feel deprived, in this case of carbohydrates, binge on a
large amount of restricted foods because of deprivation, which causes shame and
engagement in the diet cycle which leads to weight gain in the long term and is
contraindicated with Ms. W’s goals.
18. When you ask Mrs. W how much weight she would like to lose, she tells you she would like
to weigh 140, which is what she weighed before the birth of her first child. What would you
suggest as a goal for weight loss for Mrs. W?
Again, per Professor Alexander, wt loss is not a necessary primary goal for this patient. The
goal wt of 140 might or might not be realistic, but a 5-10% wt loss would be more of a
reasonable SMART goal to start with. If she is very committed to the wt loss and is willing to
commit to a kcal restriction, 140 is not an unreasonable target wt given that her IBW is
130#, however, wt loss is less important than dietary intervention reducing sodium and
saturated fat intake for her HTN and dyslipidemia respectively. Starting with a 250kcal
deficit/day for 0.5 lb/wk loss in 4 weeks (as recommended in this case study’s questions)
would result in a wt loss of 2 lbs x 4 weeks which is a 1.25% wt loss.
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19. What nutrients, components, and/or patterns in Mrs. W’s diet are of major concern to you?
- primarily Mrs. W’s diet is too high in sodium (which is the primary prupsoe of the nutrition
consult).
- her diet is also high in food with significant fat and saturated fat.
- her diet is a bit low in vegetables and fruit, though she does consume some vegetable at
dinner.
- her diet appears to provide more kcal than she needs
- her diet includes more than moderate alcohol consumption with 2 standard drinks of
alcohol, which may interfere with her medications
- her diet has significant sources of caffeine which increases BP and doesn’t help with HTN
20. Assuming that the foods in her 24-hour recall are typical of her eating pattern, outline
necessary modifications you could use as a teaching tool.
Foods Modification/Alternative(s) Rationale
1 c Coffee (black) 1 c herbal tea Decrease caffeine consumption, since
caffeine increases BP
Oatmeal (w/margarine Oatmeal packet– without Decrease saturated fat intake
& brown sugar) margarine
¼ c 2% fat milk ¼ cup 1% milk Decrease saturated fat intake
1 c Orange juice Orange fruit Increases fiber, soluble fiber helps to
decrease cholesterol
2 c Coffee (black) 1 c herbal tea, or 1 cup of Decrease caffeine consumption, since
coffee, or 1 cup black tea caffeine increases BP
1 Glazed Donut Whole wheat muffin Decreae simple CHO (generally good
practice), increase fiber, soluble fiber
helps to decrease cholesterol
Canned tomato soup Low sodium canned Decrease sodium intake to decrease
vegetable soup, home-made BP
low sodium soup if willing to
cook
1 c 2% milk 1 cup 1% milk Decrease fat/saturated fat intake to
decrease dyslipidemia
10 Saltine crackers 10 unsalted saltines Decrease Sodium intake to decrease
BP
Diet cola 16 oz water Decrease caffeine consumption, since
caffeine increases BP
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Foods Modification/Alternative(s) Rationale
2 cans regular beer ½ can beer, slice of whole Decrease alcohol consumption to
grain toast avoid hypotensive effects when
interact with medications.
6 oz Baked chicken 6oz baked chicken breast Decrease sodium to decrease BP, and
seasoned with herbs instead decrease saturated fat to decrease
of salt dyslipidemia
1 Baked potato (w/ 1 Baked potato with herbs and Reduce salt to increase sodium and
tbsp butter, S&P) garlic powder and margarine decrease BP, decrease saturated fat
(margarine has less than butter) to
decrease dyslipidemia.
1 c Carrots, glazed No complaints, perhaps eat Could eat carrots raw for more fiber,
carrots raw but glazed for flavor is fine if it means
she eats vegetables.
Salad w/ 2-3 tbsp Salad with 2/3 teaspoons of Decrease saturated fat and replace
Ranch dressing oil and vinegar (instead of with polyunsaturated fat to improve
premade dressing) dyslipidemia. Decrease sodium to
decrease BP.
2 c popcorn, buttered 1 cup popcorn, with olive oil Decrease saturated fat to decrease
w/o salt and garlic powder. dyslipidemia.
21. Activity: Access the Nutrition Care Manual https://www.nutritioncaremanual.org and the
American Heart Association website at www.heart.org.
a) Review the patient education materials available for each specific condition. You will
need to navigate through the available resources to find the printable patient
information sheets. Upload with your lab the most appropriate patient
information/education sheets that you think will be helpful for Mrs. W. Don’t forget to
mention the educational materials in your ADIME note. List materials below and upload
them with your lab assignment.
NIH Dash eating plan: https://www.nhlbi.nih.gov/education/dash-eating-plan

AHA How Do I Follow A Healthy Diet Pattern handout: https://www.heart.org/-
/media/Files/Health-Topics/Answers-by-Heart/How-Do-I-Follow-a-Healthy-Diet.pdf
NCM: Hypertension Nutrition therapy client education:
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=99
22. Write an ADIME Note and submit for grading.

▪ Write an ADIME note for Mrs. W
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Case Study - CVD
▪ 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).
▪ What would you want to reevaluate in 3 to 4 weeks at a follow-up appointment?
Name: Mrs. Wallace
Pt identifier: Ms. W
Vital Signs: BP: 150/86 mmHg (high, indicative of HTN); Pulse 80 BPM (WNL),
respirations 15 per minute (WNL)
Medical dx: HTN (hypertensive heart disease), Early COPD, overweight, dyslipidemia
Medical hx: injuries, surgeries, falls etc: no acute injuries or conditions; hx of HTN
(hypertensive heart disease) pt non-adherent with 2g Sodium diet prescribed per MD 1 yr
ago, Early COPD r/t smoking 2ppd prior to HTN diagnosis 1 yr ago, overweight,
dyslipidemia
Social hx: Pt is a 55yr old married African American woman who is not employed outside the
home and has 4 grown children. She does most of the grocery shopping and cooking herself.
She used to smoke 2ppd last year, but no longer smokes or uses any nicotine products.
Family hx: Pt’s mother passed d/t MI
Rx: Hydrochlorothiazide (thiazide diuretic) to decrease BP for HTN management,

Ramipril (Altace) (ace-inhibitor) for HTN management and stroke prevention, Atorvastatin
(Liptor) (HMG-CoA reductase/statin) to decrease cholesterol for dyslipidemia and to
prevent cardiovascular events.
OTC medications: 1 multivitamin/mineral once a day
Drug nutrient interaction concerns: Hydrochlorothiazide is potassium wasting, requiring

increased intake of potassium via increased fruit and vegetable intake. Increased K,
increased Mg (possible supplementation) and potential decreased kcal and decrease Na
consumption might be called for. Ramipril can cause anorexia and decreases in wt
which is not a problem for pt. Ramipril can decrease BP, cause dysgeusia, dry mouth,
n/v/c. It can increase K, which doesn’t seem to be an issue for pt. Taking potassium
supplements, potassium-containing salt substitutes (No Salt, Morton Salt Substitute, and
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Case Study - CVD
others), or large amounts of high-potassium foods (such as bananas and other fruit) at
the same time as taking ACE inhibitors could cause life-threatening problems. Alcohol
could exacerbate hypotension. Lipitor benefits form a diet that is lower in fat, kcal, and
cholesterol. Lipitor is atorvastatin which should not be consumed with grapefruit in any
form including grapefruit juice and derivative fruits like tangelos. It can cause N/c/d and
edema and alcohol consumption should be avoided.
Biochemical Labs:

e Abnormality
WNL, no Continue to regulate BG through low/decreased
indication of simple CHO consumption but no specific dietary
Glucose
70-110 96 insulin interventions at this time
(mg/dL)
resistiance or
T2DM
indication of this time
BUN (mg/dL) 8-20 20
CKD or
dehydration
Creatinine indication of this time.
0.6-1.2 0.9
(mg/dL) CKD or
dehydration
indication of Replace saturated and trans fats with mono- and
Total chol dyslipidemia polyunsaturated fats. Sources of monounsaturated
120-199 270
(mg/dL) fats are cold water fatty fish like salmon, sardines,
herring, mackerel, sources of polyunsaturated fats
sunflower oils.
Low 30 < 55, Decrease consumption of saturated fat (< 5-6% of
indication of kcal) and cholesterol, and trans-fat (< 1% of kcal).
dyslipidemia Replace saturated and trans fats with mono- and
HDL-chol >55 (F) polyunsaturated fats. Sources of monounsaturated
30
(mg/dL) >45 (M) fats are cold water fatty fish like salmon, sardines,
herring, mackerel, sources of polyunsaturated ftas
sunflower oils.
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Case Study - CVD
e Abnormality
indication of Replace saturated and trans fats with mono- and
LDL-chol dyslipidemia polyunsaturated fats. Sources of monounsaturated
<130 210
(mg/dL) fats are cold water fatty fish like salmon, sardines,
herring, mackerel, sources of polyunsaturated ftas
sunflower oils.
Low 75 < Decrease consumption of saturated fat (< 5-6% of
101-199 indication of Replace saturated and trans fats with mono- and
Apo A (F) dyslipidemia polyunsaturated fats. Sources of monounsaturated
75
(mg/dL) 94-178 and fats are cold water fatty fish like salmon, sardines,
(M) increased herring, mackerel, sources of polyunsaturated ftas
sunflower oils.
Apo B (F) dsylipidemia polyunsaturated fats. Sources of monounsaturated
140
(M) increased herring, mackerel, sources of polyunsaturated ftas
sunflower oils.
Triglycerides (F) dyslipidemia polyunsaturated fats. Sources of monounsaturated
150
(M) increased herring, mackerel, sources of polyunsaturated fats
sunflower oils.
Ht: 66 in / 167.64 cm
Wt: 160lbs / 72.73kg
BMI: 25.8kg/m2 , interpret BMI: High: overweight (25-29.9 is overweight BMI range)
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Case Study - CVD
IBW: 130#, 59 kg
IBW%: 123% (high IBW%; >120% of IBW indicates obesity)
UBW: 170# (last year) 160# (this year since wt loss) , 77.27kg/ 72.73kg (this year).
UBW %: 94% (UBW interpretation = wt change not indicative of malnutrition in time frame of 1
yr)
Wt change: 10lbs; 4.5 kg wt loss (2.8%) x unknown period but maintained for a year– interpret:
not <50% x 1 months so, wt change does not qualify as significant wt change
Estimated Nutrition Needs:
Kcals/day: 1611 kcal/day
Kcals/kg: 22kcal/kg = 1611 kcal/ 118.18 kg
- Method used:
Female - MSJ: (RMR=(9.99*Wkg) + (6.25Hcm) – (4.92Ayrs) – 161)
AF
AF = 1.2 because PA is walking 30 minutes 4-5 times per week which

Formula & factors
is less than 30 minutes of moderate activity per day so gernal acjtivty
Female-MSJ: (RMR=(9.99*72.73kg) + (6.25*167.64 cm) –

(4.92*55yrs) – 161)1.2 = 1611 kcal/day
Calculation & Value
Use of female MSJ because it is standard for a non-critically ill patient

who is afab like Ms. W.
AF 1.2 because PA is walking 30 minutes 4-5 times per week which is
Rationale
less than 30 minutes of moderate activity per day so gernal acjtivty
o
Protein factor 1g/kg for adult maintainaence out side of acute
Protein (g) conditions, range for acute conditosn is 0.8-1.0 g/kg,
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Case Study - CVD
72.73kg*1g/kg = 72.73g PRO* 4 g/kcal = 291 kcal from PRO,
291kcal/1611kcal* 100 = 18% (within the 15-25% recommened
by the TLC diet)
55% CHO (within 50-60% kcal from CHO)

CHO (g)
1611*0.5 = 805.5 kcal from CHO/4 kcal/g = 201.375g CHO
100-(18+55) = 27% kcal from fat (within 25-35% kcal from fat);
Total fat (g) 1611kca; *0.27 = 434.97 kcal from fat /9kcal/g = 48.33 g FAT
total
Fluid: 1611kcal(1ml/kcal) = 1611ml/day
Micronutrient needs: potassium: 4700mg/day; sodium 1500-2300mg/day: fiber 30g/day,

Calcium, 1250mg/day, Mg: 500 mg/day
Food allergies: NKFA
Diet: 2g Na
Supplement intake: 1 multivitamin/mineral once a day
PO Intake: interpret (adequate/inadequate): % meal intake is not given, presumed 100% of 24-
hr recall;
Vital Signs: BP: 150/86 mmHg (high, indicative of HTN); Pulse 08 BPM (WNL), respirations
15 per minute (WNL)
BM: no data in case study
I&O: No output data taken in case study; inputs also not specifically included
NFPE: No NFPE conducted, but Significant central adiposity; increasing risk of metabolic
conditions, indicating overweight
Food/nutrition-related hx: interpretation of 24-hr recall:
FSN 430 20 v.W19

Case Study - CVD
Pt with consumption of foods high in sodium, contributing to high BP and HTN, and increased risk of
cardiovascular event. Pt with low consumption of fruits and vegetables not negatively affecting blood
potassium level, but with dietary intervention that may change. Pt with low fiber and non-caffeinated
fluid consumption, contributing to risk of constipation. Pt with high caffeine consumption leading to
high BP, increasing HTN and risk of cardiovascular event. Pt with higher than moderate consumption of
alcohol, which may interfere with ACE inhibitor and Lipitor. Pt with consumption of overall more kcal
than needed to meet needs contributing over time to overweight. Pt with consumption of foods high in
fat and saturated fat, contributing to low HDL, low Apo A, high TG, high LDL and total cholesterol, and
high Apo B, despite pt already being on Lipitor to manage dyslipidemia.
Assessment:
Pt is a 55yr-old African American woman with dx of HTN (hypertensive heart disease), Early
COPD, overweight, dyslipidemia. Pt does not c/o any symptoms related to HTN. And denies
chest pain, SOB, syncope, palpitations, or MI. PMH not significant presents with wt loss of 10#
and maintenance of 10# wt loss within the past year and no recent wt changes. BMI 25.8
indicating overweight. Pt lives at home and does most of the cooking and grocery shopping
herself. Pt not adherent with 2g Na diet prescribed per MD last year because she believes food
is bland and tasteless without salt. Current diet is high in fat, saturated fat, simple CHO, sodium,
and caffeine, contributing to dyslipidemia and HTN respectively, thus increasing risk of
cardiovascular events. Pt would benefit from diet education strategies to decrease consumption
of sodium, kcal, fat, saturated fat and caffeine, while maintaining adequate fluid, protein, and
potassium, magnesium, and calcium. Current diet high in alcohol consumption, interfering with
ACE inhibitor and Lipitor. Pt would benefit from dietary education encouraging decreased
alcohol consumption. Pt would benefit from diet plan and diet education consistent with DASH
diet to decrease sodium intake and thus HTN and improve saturated vs unsaturated fat intake
ration and thus improve dyslipidemia.
Diagnosis:
PES #1:
Excessive sodium intake related to limited adherence to nutrition recommendations as

evidenced by 24-her dietary recall reflecting foods high in sodium and elevated BP of
150/86 mmHg.
PES #2:
FSN 430 21 v.W19

Case Study - CVD
Altered nutrition related lab values related to food and nutrition related knowledge deficit
as evidenced by 24 hr recall reflecting foods high in trans fat, saturated fat, and simple
CHO, and low HDL (30mg/dL), low Apo A (75mg/dL), high TG (150 mg/dL), high LDL (210
mg/dL) and total cholesterol (270 mg/dL), and high Apo B (140 mg/dL).
Interventions/ Nutrition Prescription
Must be written in numerical order based on priority.
1. Recommend decreasing dietary sources of sodium, fat, and simple CHO to enable
decreases in BP. Diet to provide 1611 kcal, 72.73 g protein, 201.375 g CHO, 48.33 g fat,
10.74 g saturated fat (maximum) 1611 ml fluid, <2300mg Na, 4700mg K, 500 mg Mg, 30
g fiber per day.
2. Recommend decreasing intake of dietary sources of fat and saturated fat and increasing
intake of poly- and monounsaturated fats to decrease dyslipidemia.
3. Provide nutrition education to pt regarding DASH diet principles of decreasing sodium
and saturated fat intake and increasing potassium and fiber intake.
4. Recommend decreasing caffeine intake to decrease BP and decrease risk of
cardiovascular events.
5. Recommend increasing physical activity at low frequency and intensity to facilitate
reduction of BP and improve HTN.
Goals & Strategies
Goal: Goal is decreased consumption of sodium to </= 2300 mg/day by next follow up one
month from now.
Strategies
- Provide education on reading nutrition labels and identifying sodium % DV and

understanding what that means.
- Provide education on DASH diet guidelines. Go through NIH Dash eating plan:
https://www.nhlbi.nih.gov/education/dash-eating-plan, AHA How Do I Follow A Healthy
Diet Pattern handout: https://www.heart.org/-/media/Files/Health-Topics/Answers-by-
Heart/How-Do-I-Follow-a-Healthy-Diet.pdf, NCM: Hypertension Nutrition therapy client
education: https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=99
handouts together and make sure that pt understands the dietary information by having
the patient verbally recall it to you. Have the patient create a meal plan that roughly
follows the DASH guidelines and principles and help her improve the plan she creates to
fit the guidelines, in order to increase her self-efficacy with meal planning around her
sodium and fat limitations.
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Case Study - CVD
- Brainstorm alternative methods of seasoning food that use less added salt (educate
about risks of potassium-salt alternative considering her medications, instead suggest
using herbs, capsaicin containing spices, and garlic/onion powder).
- Recommend pt make swaps of higher sodium foods to lower-sodium alternatives and
brainstorm ideas with pt that he feels comfortable with and confident in.
- Recommend pt decrease take-out meals instead invest in meal prepping. Brainstorm
with pt recipes she can make that are easy and lower in sodium (and kcal).
Goal: Goal is decreased consumption of fat to </= 120% of estimated fat need (58g of fat) and
decrease saturated fat to 100% of estimated saturated fat need (11g) by next follow up one
month from now.
Strategies:
- Provide pt with education about which foods are significant sources of fat and how to
read a nutrition label to identify fat and saturated fat.
- Recommend pt make swaps to lower fat alternatives of commonly eaten food
(particularly, switching butter for vegetable and olive oils).
- Help pt brainstorm recipes, food alternatives and strategies to decrease fat consumption
that she feels confident she can achieve. Suggest replacing foods high in saturated fat
with foods higher in mono- and poly unsaturated fats like fatty fish (salmon, mackerel)
and vegetable oils.
- Recommend pt decrease, but not eliminate, consumption of butter, margarine, sweets,
soda.
Goal: Goal is decreased consumption of simple sugars to </= 50% of current intake of simple
CHO by next follow up one month from now (to improve dyslipidemia).
Strategies
- Recommend pt decrease, but not eliminate dessert portion sizes

- Recommend pt replace consumption soda with tea and water
- Work with pt to come up with strategies he feels are realistic and is confident he can
make to decrease simple sugar intake.
- Provide education about how to read nutrition labels and identify simple sugars and what
foods are high in simple sugars.
Goal: Goal is increased intake of fruits and vegetables (to 3 x day) and fiber to >/= 90% of
recommended level (27 mg/day) to increase fiber intake, and thus soluble fiber intake which will
help to decrease LDL cholesterol and increase potassium intake by next follow up 1 month from
now.
Strategy:
FSN 430 23 v.W19

Case Study - CVD
- Encourage patient to add vegetables and fruits to meals and snacks high in potassium
(like dried apricots, winter squash, spinach, broccoli, beet greens, and bananas.)
- Encourage pt to add vegetables and fruits high in soluble fiber (lima beans, brussels
sprouts, avocado, sweet potatoes, broccoli, turnips).
- Work with the pt to determine which vegetables and fruits she prefers and would be
willing to try to incorporate into his diet and what preparing those might look like
- Brainstorm meal ideas and recipes with the pt that include vegetables and fruits.
Goal: Goal is to decrease caffeine intake to equivalent of 1 cup of coffee (80-100 mg)/day by
next follow up 1 month from now.
Strategies:
- Explain to pt that caffeine causes spikes in BP that increase the risk of cardiovascular
events, especially so in the context of her HTN.
- Help pt brainstorm alternatives to coffee and soda consumption like herbal tea, green
tea, juice, and water.
Goal: Goal is to increase physical activity to a 45 minute walk, 6 days of the week and/or light
weight lifting exercises ( a handful of exercises with 1-5 lbs of weight/resistance for about 5-10 minutes
5 days a week) by next appointment 1 month from now.
- Refer pt to PT to provide her with knowledge on how to start doing weight bearing
physical activity safely.
- Ask pt about current level of walking PA and brainstorm ways to increase.
Monitor & Evaluation
- Monitor Na, and fat, saturated fat, simple CHO, energy and overall dietary intake
by obtaining new 24-hr recall at follow up.
- Na, HDL, TG, LDL, and total cholesterol by taking new biochemical labs. Monitor
BP by taking new BP.
- Monitor Physical activity by acquiring exercise history from pt interview.
Follow-up Plan:
Nutrition Provider to follow-up a x 1 month to evaluate success of the above stated

interventions.
Indicators & Criteria for Success:
Decreased consumption of sodium with goal </= 2300 mg/day
FSN 430 24 v.W19

Case Study - CVD
Decreased consumption of fat with goal </= 58g of fat
Decreased consumption of simple sugars with goal </= 50% of previous intake of simple CHO
Increased intake of fruits and vegetables with goal of 3 x day and fiber with goal of >/= 27
mg/day
Decrease caffeine consumption with goal of < 100 mg/day.
Decrease alcohol consumption with goal of < 1 drink/day
Increase physical activity with goal of a 45 minute walk, 6 days of the week to start and/or light
weight lifting exercises (a handful of exercises with 1-5 lbs of weight/resistance for about 5-10 minutes 5
days a week.
Vitals Goal:
BP <140/90mmHg
Biochemical Labs Goals:
LDL- <100mg/dL
HDL- >55 mg/dL
total cholesterol - < 200mg/dL
TG – 35-135 mg/dL
Apo A – 101-299 mg/dL
Apo B – 60-125 mg/dL
Signature: Jen Zielke; Nutrition Provider
Date & Time: 11/16/2023; 9:00 am
Time spent with pt: 1 hour
FSN 430 25 v.W19

CVD Adime w23 Complt 1

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Case Study - CVD

CARDIOVASCULAR DISEASE & HYPERTENSION

FSN 430 1 v.W19

2. What is essential hypertension?

FSN 430 2 v.W19

3. What causes essential hypertension?

Modifiable Risk Factors Non-Modifiable Risk Factors

Increased body fat – BMI of 25.8 (> 25 –

Non-adhereance with 2g Na diet as

FSN 430 3 v.W19

a) What is metabolic syndrome?

Metabolic syndrome is a metabolic disorder of multiple etiologies including central adiposity,

b) What are the criteria? (Use NCEP or IDF criteria)

c) What are the risks?

FSN 430 4 v.W19

FSN 430 5 v.W19

a) What are stanol esters?

c) What are good sources of stanol esters (natural or manufactured sources)?

IBW 5’ 6” → 100# + 5(6”) = 130#/2.2#/kg = 59kg 59kg NA

FSN 430 6 v.W19

AF = 1.2 because PA is walking 30 minutes 4-5 times per week which

Female-MSJ: (RMR=(9.99*72.73kg) + (6.25*167.64 cm) –

Use of female MSJ because it is standard for a non-critically ill patient

FSN 430 7 v.W19

FSN 430 8 v.W19

FSN 430 9 v.W19

FSN 430 10 v.W19

FSN 430 11 v.W19

FSN 430 12 v.W19

FSN 430 13 v.W19

FSN 430 14 v.W19

NIH Dash eating plan: https://www.nhlbi.nih.gov/education/dash-eating-plan

22. Write an ADIME Note and submit for grading.

FSN 430 15 v.W19

Name: Mrs. Wallace

Family hx: Pt’s mother passed d/t MI

Rx: Hydrochlorothiazide (thiazide diuretic) to decrease BP for HTN management,

OTC medications: 1 multivitamin/mineral once a day

Drug nutrient interaction concerns: Hydrochlorothiazide is potassium wasting, requiring

FSN 430 16 v.W19

Parameter Normal Pt’s Indication/R MNT Recommendation

FSN 430 17 v.W19

Wt: 160lbs / 72.73kg

FSN 430 18 v.W19

IBW%: 123% (high IBW%; >120% of IBW indicates obesity)

Estimated Nutrition Needs:

Kcals/day: 1611 kcal/day

Kcals/kg: 22kcal/kg = 1611 kcal/ 118.18 kg

AF = 1.2 because PA is walking 30 minutes 4-5 times per week which

Female-MSJ: (RMR=(9.99*72.73kg) + (6.25*167.64 cm) –

Use of female MSJ because it is standard for a non-critically ill patient

FSN 430 19 v.W19

55% CHO (within 50-60% kcal from CHO)

Fluid: 1611kcal(1ml/kcal) = 1611ml/day

Micronutrient needs: potassium: 4700mg/day; sodium 1500-2300mg/day: fiber 30g/day,

Food allergies: NKFA

Supplement intake: 1 multivitamin/mineral once a day

BM: no data in case study

Food/nutrition-related hx: interpretation of 24-hr recall:

FSN 430 20 v.W19

Excessive sodium intake related to limited adherence to nutrition recommendations as

FSN 430 21 v.W19

Female-MSJ: (RMR=(9.9972.73kg) + (6.25167.64 cm) –

Female-MSJ: (RMR=(9.9972.73kg) + (6.25167.64 cm) –