Clinical Case Study 2: Hypertension Case Study

 

The patient is a 60-year-old black man with a type-A personality. His colleagues consider him a workaholic. He wakes up between 4:30 and 5:00 am and works until 10-11 pm. His only relaxation is cooking, especially savory dishes. He exercises moderately by walking on a treadmill for ~20 minutes per day, 2 – 3 times per week. He comes to the registered dietitian for suggestions on ways to lower his blood pressure without taking additional antihypertensive medications.

Anthropometric data:

Height: 5’9”

Weight: 234 lbs

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Nutrition-Focused Physical Findings:
Vital signs

Blood pressure: 145/92

Heart rate: 71 bpm

Respirations: 18 rf

The patient appears well nourished an in the heavy side. The remainder of the physical exam is normal except for some pain in his legs and feet, which limits his physical activity.

Social History:

He does not smoke. He drinks alcohol socially.

 

Food/Nutrition-Related History

Usual Diet:

 

Breakfast-
2 large cups of coffee , each with 1 oz half and half

2 egg omelet with 1 oz American cheese; cooked in butter

1 slice white toast with 1tbsp jelly

 

Lunch-
Deli sandwich, generally 4 oz ham and 2 oz swiss cheese with 1 tbsp mustard

 

Snack-

Coffee with 1 oz half and half

 

Dinner-

Grilled steak, ~8 oz seasoned generously with Montreal steak seasoning

1 cup French fries with salt and 2 tbsp ketchup

Iceberg lettuce with 2 slices crumbled bacon, 2 tbsp blue cheese dressing

16 oz diet tonic water

 

Snack-

1 cup premium brand ice cream

 

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Medications:

Hydrochlorothiazide

Supplements:

None

 

Questions:

1. Define hypertension, suggest how his high blood pressure would be classified, and discuss how his hypertension affects his risk for future health problems.

 

Hypertension is chronic elevation in blood pressure classified by Stage 1 and Stage 2.  This patient has blood pressure of 145/92 mm Hg, which would be classified as Hypertension, Stage 1 because his systolic is between 140-159 mm Hg and diastolic is between 90-99 mm Hg.  It would also be classified as Primary or essential, meaning there is no known cause, given the information we were provided for this case study.  Hypertension is a risk factor for many cardiovascular disorders as well as kidney disease.  This is due to hypertension individuals exhibiting excessive secretion of vasopressin from the hypothalamus; vasopressin, as well as angiotensin II, causes constriction and fluid retention, which increases blood pressure.  Hypertensive individuals may also have a genetic predisposition to producing more angiotensin, which by itself would increase blood pressure.  Hypertension puts great strain on blood vessels, makes them weaken and predisposes them to damage.  Once blood vessels are weakened, they are more likely to become blocked, which can cause stroke.  Untreated hypertension can also cause heart failure due to the increased pressure of the blood; the heart muscle can be very thick and cause angina (chest pain).  High blood pressure may also cause blood vessels walls to thicken and deposit cholesterol, which increases risk of heart attack and stroke.  The heart also has to work much harder to keep blood circulating throughout the body. 

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  2. What is his IBW, %IBW, and BMI? Estimate his caloric requirements for weight loss. Show your work.

 

IBW=106+6(9)=160 lbs /2.2= 72.73 kg

IBW % = 106.36 kg / 72.73 kg = 146.25%

BMI= [234 lb/(69 inches2)] X 703 = 34.55 = Obesity, Grade I

 

  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?

 

The DASH eating plan includes eating less sodium, sweets, added sugar, sugar-sweetened beverages, fats and red meats; it is a diet rich in fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, beans, seeds, poultry, fish, and nuts.  For a 2,100 calorie eating plan the following nutrient goals used in the DASH eating plan are as followed:

6% of calories from saturated fat, 150 mg of cholesterol, 30 grams of fiber, 2,300 mg of sodium, 4,700 mg potassium, 1,250 mg calcium, and 500 mg magnesium, as referenced by the NIH NHLBI; these are values to be under or at.  If this patient follows the DASH diet it is expected that he would have reductions in overall blood pressure; would likely see reductions in systolic and diastolic blood pressures.  Specifically, this patient could see a SBP reduction of 8-14 mm Hg.  The DASH diet has also been shown to decrease LDL cholesterol, HDL cholesterol, apolipoprotein A-I, intermediate density lipoprotein and large LDL particles; it has also been shown to decrease triglycerides and large and medium very-low-density lipoprotein particle concentrations. 

 

  4. Analyze his diet using MyPlate superTracker. 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?

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Currently he is consuming roughly 2,212 calories (some assumptions had to be made due to food record missing details) based on the 1 food record presented (normally would want to see about 7 food records/recalls to observe usual intake) (these values can be seen on the page below).  Using the Mifflin St. Jeor equation this patient’s energy needs were calculated as follows:

10 ( 106.36 kg) + 6.25 (175.26 cm) – 5 (60 years  old) + 5 = 1,863.98 k cals ( AF of 1.2) – 500 calories to promote weight loss = 1,736.78 calories

Therefore, this patient is consuming over the recommended caloric intake as calculated above in order to promote weight loss.

It should be noted this patient is consuming a diet that greatly exceeds the sodium recommendations for a DASH diet; this patient on the assessed day consumed 9,638 mg sodium, when the DASH diet recommends 2,300 mg or less.  The DASH diet also recommends 6% of calories from saturated fat, and this man was over consuming roughly 23% of his daily calories from saturated fat.  This man was also over in cholesterol consuming 860 mg, which is over the DASH diet recommended 150 mg.  The DASH diet also recommends 30 grams of fiber, and this patient consumed only 6 grams.  This patient was also under in potassium intaking 3,143 mg (under the DASH diet’s 4,700 mg), and was also under recommendation of magnesium; he was consuming 199 mg magnesium when the DASH diet recommends 500 mg.  The patient was consuming 1,248 mg calcium, which was just under the DASH recommended value of 1,250 mg calcium.  *This analysis is based off of one food record with minimal preparation data; usually we would like to see multiple food records, preferably ~7 days, in order to categorize as ‘usual’ or ‘habitual’ intake.

 

 

  5. What type of medication is he on for his blood pressure? Does it have any food–drug interactions?

 

This patient is on hydrochlorothiazide, which has food (nutrient) and drug interactions.  Calcium, sodium, potassium, magnesium, zinc, and vitamin D may be decreased due to thiazide being a diuretic and promoting increased losses of such nutrients in the urine via kidney excretion mechanisms.  Studies have shown a decrease in folic acid in individuals taking diuretics for more than 6 months; therefore folic acid levels may want to be assessed for possible replenishment of them due to losses via the medication.  There also is a vast number of drugs that should be avoided while on this medication, such as aspirin, naproxen, salicylic acid, and methotrexate; a full list of drug interactions can be found from the Mayo Clinic here.

 

  6. Identify an appropriate nutrition diagnosis and write a PES statement.

• Food and nutrition related knowledge deficit related to consuming a diet high in sodium, cholesterol, and saturated fat as evidenced by food record provided showing a diet high in sodium, cholesterol, and saturated fat, elevated total cholesterol of 238 mg/dL, high LDL cholesterol 174 mg/dL, low HDL cholesterol of 35 mg/dL, higher TGs of 133 mg/dL, and having hypertension with BP 145/92 mm Hg.

• Excessive sodium intake related to poor food choices as evidenced by consuming a diet high in sodium as per food record provided showing intake of 9600 mg in one day.

• Excessive fat intake related to high consumption of high-fat animal products as evidenced by food record containing American cheese, ham, steak, and crumbled bacon.

• Inadequate fluid intake related to busy schedule and knowledge deficit as evidenced by no documentation of water on food record.

• Physical inactivity related to busy work schedule and patient reported pain in legs and feet as evidenced by patient reporting moderate exercise for about 20 minutes 2-3 times per week.

 

  7. 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?

The patient’s MDRD study equation is 75 mL/min/1.73m2.  The GFR category is a G2, which does not fulfill the criteria for chronic kidney disease if these readings persisted for at least three months.  Therefore, his hypertension is not doing a great deal of damage to his kidneys as his creatinine levels suggest now, but if they rise due patient not complying to recommendations, they may pose a threat to kidney status in the future.

 

  8. Calculate this patient’s 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk using the following link: http://www.cvriskcalculator.com/

 

The patient’s 10-year risk of heart disease or stroke is 19.3%.  The calculator then suggests the following:

• Discuss starting aspirin with your doctor

• Suggests you should be on a high intensity statin

• Blood pressure is poorly controlled and should initiate lifestyle interventions and consider starting thiazide diuretics or calcium channel blocker

 

  9. Suggest specific modifications of diet and lifestyle (interventions) that might lower this client’s blood pressure.

 

Overall I would suggest a DASH diet for this patient, encourage him to work less (if at all possible) and take more time to himself in order to increase his physical activity.  I would suggests this client changes his diet to a DASH diet lowering his sodium, cholesterol, saturated fat intake, and increasing his intake of foods that contain potassium, fiber, magnesium, and calcium.  Due to the medication he is on, I would also like to see the patient consuming foods with zinc and vitamin D; this patient may need to be put on a vitamin D supplement, as most people are deficient, it is difficult to obtain adequate levels through diet, and his medication may be further lowering levels. A Dash diet would increase his fruit and vegetable intake, fat-free or low-fat milk and milk products, whole grains, beans, seeds, poultry, fish, and nuts intake.  A DASH eating plans consists of 7-8 daily servings of grains and grain products, such as cooked rice or whole wheat bread; this would increase fiber intake and be a major source of energy for the patient.  4-5 vegetables should be consumed per day, as well as 4-5 fruits; these will increase potassium, magnesium, and fiber intake.  Low-fat or fat-free dairy foods should be consumed, such as low-fat or fat-free cheese, which can serve as a course of calcium and protein.  I would encourage the patient to select only lean cuts of meat, including poultry or fish and eat 2 servings or less per day; this will help boost magnesium intake.  The patient should also introduce more nuts and seeds to his diet 4-5 times per week, such as almonds, peanuts, beans, lentils; the patient should be sure the nuts are un-salted and to rinse beans from a can to reduce sodium intake.  These plant sources will increase his fiber intake, as well as potassium and magnesium.  I would like to see the patient use oil-based salad dressings to boost his consumption of PUFAs; he should have about 2-3 servings per day of healthy fats.  I would allow the patient to have sweets about 5 times per week, such as jellybeans or sorbet.  Focusing on the right foods will allow the proper nutrients to follow!

 Regarding physical activity, I would encourage the patient to try to walk everyday if he can, and even on days where he has less time, do more high intensity training such as jogging/running or weight training for a shorter amount of time.  These diet and lifestyle modifications should decrease his blood pressure and improve his overall quality of life.

 

  10. What are your overall goals for this client, and how would you monitor the results or outcomes of your interventions?

 

One goal for this client would be to educate him on foods that consist a DASH diet, and see if he could identify foods that would be good to eat on this new diet regimen; this could be monitored by doing food recalls or food records with him after providing nutrition education on the DASH diet.  I would encourage him to work towards his goal of eating 2-3 vegetables with each meal; slowly progressing to this and drinking adequate amounts of water due to the increased fiber intake.  Due to his gradual increase of fruits and vegetables, I would encourage more water intake throughout the day to help offset the increased fiber in his diet, and to meet adequate levels of water intake (since right now he does not seem to be consuming any as per food record).  I would perform diet analysis to assure he is consuming less sodium, saturated fat, and increasing his fruit and vegetable intake, as well as healthy fats via diet recalls or diet food records.  I would like to perform at least 7 food records to see his new usual intake.

I would also have a goal for the patient to see if he can cut back hours working in order to decrease his stress and allow more time to relax by cooking.  Because the patient enjoys cooking I would encourage him to cook and meal prep healthy dishes for him to eat so on days when he does have to work long he has nutritious foods to keep him fueled.  I would suggest DASH Diet cookbooks for him to get or provide recipes for him to get started on that are tailored to his likes.  I would monitor this goal by speaking with the patient about his stress level, and via the food recalls or records to see if he prepped/cooked his meals or ate out, and what those meals look like.

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I would also have the patient track his physical activity to see if he has increased his physical activity; perhaps a pedometer could be used, or the tracking devise on his phone if he has an iPhone, if an exercise log is not being used.  One goal for his physical activity is to up his low-to –moderate physical activity to 30-45 minutes most days of the week.  I would encourage the patient to get orthotics in his shoes to help with his foot and leg pain if such resources are available to him.  If not I would encourage swimming in a pool, maybe to join a gym if needed and able to, to allow him to move without being in pain.  To see if these modifications are lowering his blood pressure I would check his blood pressure (or have his primary care doctor check it) to see if his blood pressure has gone down without taking additional medication.  I would also track his weight to see if the increased physical activity has promoted weight loss, in conjunction with his new diet; weight loss may help relieve pressure and pain from his feet and legs.