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Hypertension Case Study

David Camilleri
NFS 2420
Professor Okonkowski
FALL 2014

Hypertension
Blood pressure (BP) is the measurement of the force of blood flow on the walls of the arteries
as the heart pumps blood throughout the body. The number is given as a two-part reading, such as
120/80 mmHg; systolic and diastolic, respectively. The systolic pressure is the pressure when the heart
beats, and the diastolic pressure is the pressure when the heart rests between beats. If an individual has
120/80 mmHg most of the time, they are considered to have normal pressure. If their numbers are
between (120-139)/(80-89) mmHg most of the time, they are considered Pre-hypertension. If their
numbers are greater than 140/90 mmHg most of the time, they are considered to have hypertension.
If one number is within range but the other is high, it has possible to have systolic hypertension or
diastolic hypertension. For example, a BP of 150/75 mmHg would be considered systolic
hypertension. Hypertension is also commonly referred to as high blood-pressure, or HBP.
In 2012, in the United States alone, hypertension was present in 32.5% of the population over
the age of 20. This number is even higher in those over the age of 50, affecting a staggering 50-70%.
The demographic with the highest prevalence of hypertension are African Americans. Blood pressure
increases with age due to the hardening of the lining of the aorta and other arteries, referred to as the
intima. The body's other blood vessels also lose elasticity over time, creating greater force as the heart
pumps blood throughout the body. This physiological change causes the aging heart to have to work
harder to pump blood, which ultimately shortens the life of the heart.
The major area of concern associated with hypertension is the heart. Hypertension puts the
aging adult at a dangerously high risk for coronary artery disease, heart attack and heart failure. Adults
with hypertension are at a greater risk for heart attacks than those without. Some evidence suggests that
the population with the greatest risk for heart attack are those of South Asian decent.
Another problem associated with hypertension is the increased risk for stroke. A stroke occurs
when the blood supply to the brain is blocked (ischemic stroke) or a blood vessel ruptures (hemorrhagic
stroke). Both cases can cause oxygen loss to the brain, which very quickly causes the affected part of

the brain to essentially die. This not only affects the brain, but can also cause the part of the body that is
controlled by the different areas of the brain to malfunction. Some common areas affected are those
responsible for language, speech and vision. According to the American Heart Association, stroke is the
fourth most common cause of death among Americans, and hypertension is the easiest modifiable risk
factor for stroke.
Another common problem with hypertension is its affect on the kidneys. Because the kidneys
are filled with many blood vessels, they are particularly susceptible to damage. As the vessels narrow,
weaken or harden, they lose the ability to supply adequate blood flow through them, causing tissue
damage. Since the kidneys are responsible for filtering the blood, this can be extremely problematic if
left untreated. The kidneys and HBP are closely related due to the kidney's ability to control blood
pressure by releasing the hormones renin and angiotensin, which decreases as the kidneys begin to fail
due to HBP.
As mentioned, race can have an affect on an individual's risk for hypertension. In addition,
consumption of alcohol in excess (more than 2 drinks daily for men/ more than 1 drink for women) can
increase one's risk. Having high levels of cortisol, the stress hormone in the blood can also be
detrimental. Also, having a high Body Mass Index (BMI), as well as a lack of exercise or a sedentary
lifestyle are problematic. In regards to diet-related risk, too much sodium in the diet, or a diet low in
calcium, potassium, and magnesium are the most common diet-related risks.
Fortunately, hypertension is both curable and preventable if appropriate dietary and lifestyle
modifications are employed as early as possible. As with any disease, prevention is the best method.
One of the best ways to prevent hypertension is to assess your risk based on your diet and lifestyle as
well as frequently checking your blood-pressure. This can be done at home using a digital bloodpressure measuring device. This should be done at the same time everyday to ensure accurate results.
This can also be done by your primary care physician.
Diet also plays a major role in the prevention and treatment of hypertension. A common diet

used for the management and prevention of hypertension is the DASH (Dietary Approaches to Stop
Hypertension) diet. This diet is very effective for aging adults without kidney failure but is not
recommended for older adults with kidney failure. The DASH diet has an emphasis on low-fat dairy
products, as well as whole grains, fish, poultry and nuts. It also restricts red meat, saturated fats, and
sweets. Carbohydrates are also reduced and substituted for plant based proteins and monounsaturated
fats.
The American Heart Association provides a set of guidelines for hypertension management with
an emphasis on diet-related approaches. These include keeping total sodium intake to 1500 mg/day. In
addition, they recommend eating 8-10 servings of fruits and vegetables daily, with an emphasis on
those that contain potassium. Examples include bananas, squash, dark-leafy greens, and avocados.
They also recommend eating healthy proteins, such as skim milk, low-fat dairy products, cod, salmon,
beans, legumes, and skinless poultry. They also recommend maintaining a healthy weight and at least
2.5 hours of moderate exercise per week for healthy adults.
Hypertension and its related damage to the body is a significant problem in the United States
and worldwide. According to the Center for Disease Control (CDC), in 2009, hypertension was
responsible for more than 348,000 deaths, as well as 47.5 billion dollars in related costs. HBP is a
problem that affects 1 in 3 American adults (pre-hypertension), and is a problem that is easily
controlled or prevented through diet and lifestyle modification.
Patient Information
My patient is a 69-year-old male. He is 6 foot 2 inches tall and weighs 253 pounds. This gives
him a BMI of 32-33, which is considered obese. His average blood-pressure is 154/95 mmHg, which
makes him diagnosable as having hypertension. His total cholesterol is 232, which is considered
borderline high cholesterol. His high density lipoprotein (HDL) or good cholesterol is 34, which is
considered low. His desirable total cholesterol should be 200 or less and his HDL should be 45 or
greater.

His current medications include Diltiazem, a calcium channel blocker, used to treat HBP. In
addition, he is taking Lasix, a loop diuretic, which treats fluid retention (edema) and HBP. He also
takes Melatonin, a hormone created in the body that helps regulate sleep, Noni, a fruit that is believed
to help lower cholesterol and blood-pressure, and magnesium, an important mineral that is a cofactor
for hundreds of enzyme reactions. He also drinks coconut water, which contains high levels of
potassium and magnesium, as well as many antioxidants.
He is currently working as an accountant, and is in his vehicle for at least 2 hours a day. He does
not like to exercise, and finds it difficult to do so because of his busy work schedule and his various
social activities with his grandchildren.
Harris-Benedict Equation
To determine his total caloric intake necessary for weight loss, the Harris-Benedict equation can
be used as a guide to create a starting point for a successful weight loss plan. The following equation
was used:
BMR = 88.362 + (13.397 x weight in kg) + (4.799 x height in cm) - (5.677 x age in years)
2136.0954 = 88.362 + (13.397 x 114.759) + (4.799 x 187.96) (5.677 x 69)
2136 x 1.2 = 2563 kcal/day to maintain current weight.
2563 x 0.8 = 2050 kcal/day to lose weight based on a 20% reduction in calories.
Nutrition Care Plan
In order to facilitate a successful outcome for the patient, a Nutrition Care Plan (NCP) will be
used to serve as a rubric to assist the patient in reaching a healthier nutritional status. The NCP involves
a four step process. The process includes assessment, diagnosis, intervention and evaluation.
Assessment involves collecting as much data from the patient as possible. This may include
medical history, test results, current nutritional status, etc. It is important to collect as much information
as possible to ensure a successful assessment of the patient's needs as well as their lifestyle to create a

plan that is tailored to their needs. No two NCPs are the same.
Once a thorough assessment has been made, the data presented is then used to diagnose any
nutrition-related problems or areas of concern. The diagnoses step is equally as important as the initial
assessment because a problem may still be present after treatment if not properly diagnosed the first
time.
After the areas of concern have been identified through the diagnosis step, intervention can
begin. Intervention is the backbone of the Nutrition Care Plan. It is the set of actions needed to reach
the goals of the patient and healthcare professional. A successful intervention involves actions that are
feasible by the patient, which is why gathering as much background information as possible is a
necessary first step. For example, it would be unreasonable to expect an elderly patient with
osteoporosis who is 100 pounds overweight to return to a healthy weight in 3 month's time with a
rigorous exercise regimen. Lifestyle factors such as socio-economical status, cultural differences, and
even their job can all be used to determine the best course for intervention.
Even with an excellent NCP, it is crucial to follow up with the patient and evaluate their
progress and create modifications as necessary. It is nearly impossible to predict every scenario that
may occur when the patient leaves with their NCP. The level of success is directly related to the level of
modification needed. A higher level of progress warrants less intervention, which is always an ideal
scenario.
My Patient's Nutrition Care Plan
1. Assessment:

Food/Nutrition-Related History- No caloric intake data available. Consumes coconut water and
Noni daily.

Anthropometric Measures- 69 years of age. Male. 6'2'' tall. 253 pounds. 32-33 BMI (Obese).
Appears obese.

Biochemical Data, Medical Tests and Procedures- BP is 154/95 mmHg. Total Cholesterol is
232. HDL is 34.

Patient History- Works as an accountant. Very busy schedule. Sedentary lifestyle. Drives 2+
hours daily. Doesn't like to exercise. Likes to do social activities with grandchildren.

2. Diagnosis:

Food and/or Nutrient Intake- Likely eats poor food choices due to busy schedule.

Medical- Is overweight by ~70 pounds. Has hypertension. At high-risk for cardiovascular


disease and stroke based on age, biochemical data and medical tests.

Behavioral/Environmental- Likes to spend time with grandchildren. Puts his work and social
life before his own health. Stress is likely present due to busy schedule.

3. Intervention:

Food and/or Nutrient Delivery- Keep a food intake log for 7 days to establish nutrient intake
and caloric intake. Establish 3-day menu for weight loss. Initial kcal/day is set at 2200, to be
slowly tapered down to 2050 kcal/day based on patient feedback and energy levels. Intake may
be raised to 2500 kcal/day to maintain once target weight of 165-170 is reached.

Nutrition Education/Counseling- Educate patient on proper nutrition via printed materials that
can be incorporated into patient's schedule. Answer any questions patient has and provide
additional resources for information.

Coordination of Nutrition Care- Work with patient and patient's family to establish a support
system. Incorporate exercise into social activities with family. Work with primary care
physician to perform scheduled biochemical tests and monitor blood-pressure. Also, adjust
medications as deemed necessary by physician.

4. Evaluation:

Food/Nutrition-Related Evaluation- Evaluate food intake log provided by patient and discuss

areas of concern. Follow up monthly to check progress and address any areas of concern.

Anthropometric Measures- Ensure that progress meets criteria established after assessment of
daily caloric intake.

Biochemical Data, Medical Tests and Procedures- Use data provided by primary care physician
and modify diet as needed.

Nutrition-Focused Adjustments- Modify as needed.


3-Day DASH Diet Plan

Total Calories: 2200


Macronutrient Calorie Distribution:
55% Carbohydrates (303 grams)
18% Protein (99 grams)
27% Fat (66 grams)

Other Considerations:
Water- Drink as much as possible.
Cholesterol- 150 milligrams or less per day.
Fiber- At least 30 grams per day.
Sodium- 1500 milligrams or less per day.
Fat- Plant based are best. Low saturated fat. High monounsaturated fat.
Other Vitamins/Minerals- High potassium, calcium, and magnesium

Day 1:
Breakfast- 8 oz coconut water, 1 hardboiled egg, Steel cut oats.
Snack- Red pepper slices with guacamole.

Lunch- Low-sodium tuna salad on wholegrain bread with tomato and spinach. 8 oz pomegranate juice.
Snack- Unsalted almonds and lite-cheese stick.
Dinner- Kale and field green salad with grilled chicken, vinegar and olive oil dressing. Greek yogurt.
Day 2:
Breakfast- Shredded wheat cereal with skim milk and raspberries. 8 oz noni juice.
Snack- Snack mix (walnuts, cranberries, apricots, pepitas).
Lunch- Low-sodium canned lentil soup and vegetable chips with salsa.
Snack- Baby carrots and broccoli with low-fat ranch.
Dinner- Broiled salmon with brown rice and marinara sauce.
Day 3:
Breakfast- Whole-wheat english muffin with egg white, low-fat cheese, and Canadian bacon.
Snack- Greek yogurt with snack mix and granola.
Lunch- Chicken, guacamole, salsa, and field green wrap with whole wheat lawash. 8 oz coconut water.
Snack- Multigrain bagel with low-fat cream cheese.
Dinner- Tomato, mozzarella, and basil salad, baked potato. 4 oz red wine.
Drug/Drug & Drug/Nutrient Interactions
Lasix:
Electrolyte Loss- It is possible that with loop diuretics, including Lasix, that their may be a reduction in
sodium, calcium, potassium, and magnesium. This is likely not going to be an issue due to the coconut
water and magnesium that the patient supplements, as well as the DASH diet.

Diltiazem:
Alcohol- Alcohol, which can lower blood pressure, may intensify the effects of Diltiazem. The 3-day
menu includes 4 oz. of red wine on the third day with dinner. This small amount should not be an issue

if only drank on a rare basis.

Grapefruit- Grapefruit and grapefruit juice may also increase the effects of Diltiazem by increasing its
level in the blood. This should be avoided if possible.

Aspirin- May cause unusual bruising or bleeding. Do not take without talking to your prescribing
physician.

Works Cited
Bernstein, Melissa, and Ann S. Luggen. Nutrition for the Older Adult. Sudbury: Jones and Bartlett
Publishers, 2010. 127-30. Print.
"Blood Pressure Facts." Center for Disease Control and Prevention. Center for Disease Control and
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"HBP High Blood Pressure." PubMed Health. National Library of Medicine, 13 May 2014. Web. 18
Nov. 2014. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/>.
"High blood pressure - cause." WebMD. N.p., 12 Mar. 2014. Web. 21 Nov. 2014.
<http://www.webmd.com/hypertension-high-blood-pressure/tc/high-blood-pressurehypertension-cause>.
"High blood pressure." Medline Plus. National Library of Medicine, 13 May 2014. Web. 18 Nov. 2014.
<http://www.nlm.nih.gov/medlineplus/ency/article/000468.htm>.
"Stroke and High Blood Pressure." American Heart Association. The American Heart Association, 13
Aug. 2014. Web. 1 Dec. 2014.
<http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/WhyBloodPressureMatters
/Stroke-and-High-Blood-Pressure_UCM_301824_Article.jsp#>.
Ulmer, Graham. "Dash Diet Proportions: Carbohydrates, Fat & Protein." LiveStrong. LiveStrong, 23
Feb. 2014. Web. 3 Dec. 2014. <http://www.livestrong.com/article/455388-dash-dietproportions-carbohydrates-fat-protein/>.