ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Section F- Group 3

SALIENT FEATURES OF THE CASE

MYOCARDIAL INFARCTION
TYPE II DIABETES MELLITUS

HYPERTENSION

GOALS

To achieve maximum rest for the heart

To maintain good nutrition

To achieve mild degree of weight loss

To encourage acceptability of the program to the patient

Hypertension

Lifestyle Modifications to Manage Hypertension

A. Weight Reduction

Maintain normal body weight (BMI, 18.5-24.9)

Approximate Systolic BP reduction (5-20 mmHg/10kg weight loss)

B. Adopt DASH eating plan

consume a diet rich in fruits, vegetables, and low fat dairy products

with a reduced content of saturated and total fat

C. Dietary Sodium

reduce dietary sodium, no more than 100meq/L

D. Moderation of Alcohol consumption

no more than 2 drinks/day ( 1 oz or 30mL ethanol) in most men

and no more than 1 drink/day in women

Dietary Management

Calorie

decreased in obese and overweight

Protein
 adequate to maintain nitrogen equilibrium

Carbohydrate

decreased since it is the major source of energy

Fat

decreased to 25% of the energy requirement; more poly-unsaturated fats recommended

Fruits and Vegetables

increased to supply vitamins and minerals and fibers

Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction

Consume an overall healthy diet

Aim for a healthy body weight

Aim for recommended levels of LDL and LDL cholesterol, and triglycerides

Aim for a normal blood glucose level

Be physically active

Avoid use and exposure to tobacco products

Balance calorie intake and physical activity to achieve or maintain a healthy body weight

Consume a diet rich in vegetables and fruits

Choose whole grain, high fiber foods

Consume fish, especially oily fish, atleast twice a week

Limit your intake of saturated fat to <7% of energy, transfat to <1% of energy and cholesterol to
<300 mg/day by

choosing lean meats and vegetable alternatives

selecting fat-free (skim), 1% fat and low fat dairy product and minimizing intake of partially
hydrogenated fats

Minimize your intake of beverages and foods with added sugars

Choose and prepare foods with little or no salt

If you consume alcohol, do so in moderation

The guidelines are designed to assist individuals in achieving and maintaining:

1. A healthy eating pattern including foods from all major food groups

2. A healthy body weight

3. A desirable blood cholesterol and lipoprotein profile

4. A desirable blood pressure

DIET RESTRICTIONS

Limit salt intake

Reducing sodium intake by 1.8 g/d can reduce systolic and diastolic BP of 4 and 2 mmHg in
hypertensives

AHA guideline-Limit salt intake to 6 g/day=2400 mg of sodium/day

Some salt may be used in cooking but no salty foods are permitted

No salt is used at the table

Limit alcohol intake

No more than 2 drinks/day (1 oz or 30 mL ethanol, 24 oz beer)

Adopt Dietary Approaches to Stop Hypertension (DASH)

Diet rich in fruits, vegetables, and low fat dairy products with reduced content of saturated
and total fat

DURING HOSPITAL STAY

DIET MANAGEMENT

After a heart attack, give nothing by mouth or just sips of cool water

Then, supplement parenteral dextrose solutions for the 1st 24 hours

2nd-3rd hospital day, low-fat liquid diets that supply 500-800 kcal and 1000-1500 ml of liquid
given in small frequent feedings

Food is given at room temperature

Caffeine is strictly prohibited due to its stimulating effects on the heart

The patient then progress to soft diet after 3 days

68 y/o, 80kg, 54 (163cm)

A. BMI= Weight [kilograms] / Height [meters]2

= 80kg/2.66m

= 30.08 (Obese class 1)

B. IDEAL Body Weight (IBW)

IBW= (Ht. in cm 100) [(Ht. in cm 100) x 10%]

IBW= (163cm 100) [(163cm 100) x 10%]

= 63 - (63 x 0.1)

= 63 6.3

= 56.7kg

C. Gomez Classification

%IBW = ABW/IBW x 100%

= 80kg/56.7kg x 100%

= 141%

*Use corrected body weight if % IBW is >125%

D. Corrected Body Weight

CBW= IBW + ((ABW IBW) x 25%)

= 56.7 kg + [(80kg 56.7kg) x 25%]

= 56.7 kg + (23.3 x 0.25)

= 56.7 kg + 5.8

= 62.5 or 63kg

* Use 63 kg in computing TER instead of 56.7 kg

E. Harris-Benedict equation (BMR determination)

Men (68 y/o, 63kg CBW, 163cm)

BMR = 66 + (13.7 x weight in kg) + (5 x height in cm)

- (6.8 x age in years)

= 66 + (13.7 x 63kg) + (5 x 163cm) - (6.8 x 68 y/o)

= 66 + 863 + 815 - 462

= 1282 or 1300kcal

F. Total Caloric Requirement

TCR= BMR x Activity Factor x Injury Factor

= 1300 kcal x 1.3 (very light activity) x 1.5 (severe stress)

= 2535 or 2500 kcal

DIETARY MANAGEMENT

PROPOSED DIET: LOW SALT, LOW FAT, LOW GLYCEMIC FOOD

Calorie- decreased since the patient is obese

Carbohydrate- decreased since its the major source of energy

Protein-adequate to maintain nitrogen equilibrium

Fats- decreased by 25% of the energy requirement, more polyunsaturated fats are recommended

NUTRIENT DISTRIBUTION BASED ON TER:

Nutrient Percentage

Carbohydrate 55-70%

Protein 10-15%

Fat 20-30%

CALCULATION OF MACRONUTRIENT DISTRIBUTION BASED ON TCR:

CHO
2500 X 0.6 1500 kcal 1500/ 4g 375 g
(60%)

CHON
2500 X 0.15 375 kcal 465/ 4g 93.75 g or 95 g
(15%)

FATS
2500 x 0.25 625 kcal 625/ 9g 69.4 or 70 g
(25%)

DIET PRESCRIPTION

Rx Kcal 2500 kcal

CHO 375g, CHON 95g, Fats 70g

60% 15% 25%
Diet Rx 2500 kcal CHO 375g (60%) CHON 95g (15%) Fats 70g (25%)

FOOD LIST No. of exchanges CHO (g) CHON (g) Fat (g) Energy (kcal)

IA Veg A 8 12 (3) 4 (1) - 64 (16)

IB Veg B 8 24 (3) 8 (1) - 128 (16)

II Fruit 5 50 (10) - - 200 (40)

III Milk 2 24 (12) 16 (8) 10 (5) 250 (125)

IV Sugar 3 15 (5) - - 60 (20)

Partial sum 125

375 (prescribed CHO)

- 125 ( partial sum CHO)

= 250 / 23 = 11 exchange rice

V Rice 11 253 (23) 22 (2) - 1100 (100)

Partial sum 50

95 (prescribed CHON)

- 50 (partial sum CHON)

= 45 / 8 = 6 exchange meat

VI Meat (LF) 6 - 48 (8) 12 (2) 300 (50)

Partial sum 22

70 (prescribed fat)

- 22 (partial sum fat)

= 48 / 5 = 9 exchange fat

VI Fat 9 - - 45 (5) 405 (45)

TOTAL 378 98 67 2507

A Days Exchanges Between Meals and Snacks

AM PM MN
Exchange group No. of exchange Breakfast Lunch Dinner
snack snack snack

Veg A 8 2 3 3

Veg B 8 2 3 3

Fruit 5 2 2 1

Milk
2 1 1

Sugar 3 1 1 1

Rice 11 2 2 2 2 2 1

Meat (Low Fat) 6 2 2 2

Fat 9 2 2 3 2

Breakfast

FOOD LIST EXCHANGE MENU

1 cup cooked malunggay

Veg A 2

1 cup cooked kalabasa

Veg B 2

Fruit 2 2 slices of pineapple

Milk 1 4 tbsp low fat or skimmed milk

Rice 2 1 cup rice, cooked

Meat 2 1 cup cooked mashed garbansos (chickpea seeds)

Fat 2 2 tps. Vegetable oil

Pumpkin malunggay and chickpea porridge, pineapple with skimmed milk

AM Snack

FOOD LIST EXCHANGE MENU

Sugar 1 2 tsp jellies

Rice 2 6 pcs kutsinta

Fat 2 4tbsps coconut grated

Kutsinta with jellies and grated coconut

Lunch

FOOD LIST EXCHANGE MENU

1/2 cup sili leaves, cooked

Veg A 3
1 cup sayote, cooked

Veg B 3 3 tbsps atsara (pickled papaya)

Rice 2 1 cup rice, cooked

1/2 breast chicken

Meat 2
1 pc medium size grilled tilapia

Fat 3 1 1/2 medium size Avocado

Tinolang manok, Grilled tilapia with rice and atsara ,

avocado

PM Snack
FOOD LIST EXCHANGE MENU

Fruit 1 1 medium slice Mango, ripe

Sugar 1 2 tsp orange drink dissolve in glass of water

Rice 2 2 slices sapin-sapin

Sapin sapin, ripe mango and orange juice

Dinner

FOOD LIST EXCHANGE MENU

1 1/2 cup cauliflower, cooked

Veg A 3

1/2 cup carrot,cooked

Veg B 3 1/2 cup onion,cooked

1 tablespoon green peas, canned

Fruit 1 1 small Banana, lakatan

Milk 1 1/2 cup yoghurt

Rice 2 1 cup of rice, cooked

Meat 2 2 pc (3 cm cube) beef (lean meat)

5 pcs pili nut

Fat 2
2 tsp peanut butter

Beef stew with rice, yoghurt with banana, peanut butter and pili nut

MIDNIGHT SNACK
FOOD LIST EXCHANGE MENU

Fruit 1 1 small apple

Sugar 1 1/2 tbsp ube halaya

Rice 1 2 pcs Pan de sal 7x4 cm

Pan de sal with ube halaya and fresh apple juice

DISCHARGE PLAN
DIET MANAGEMENT
Normal solid diet
Based on weight status and blood lipid levels
In patients who are obese, an exercise regimen must be instituted

Total Caloric Requirement

TCR= BMR x Activity Factor x Injury Factor
= 1300 kcal x 1.6 (light activity) x 1.35 (moderate stress)
= 2808 kcal or 2800 kcal

CALCULATION OF MACRONUTRIENT DISTRIBUTION BASED ON TCR:

 CHO
2800 X 0.6 1680 kcal 1680 / 4g 420g
(60%)

CHON
2800 X 0.15 420 kcal 420/ 4g 105g
(15%)

FATS
2800 x 0.25 700 kcal 700/ 9g 77.78g or 80g
(25%)

DIET PRESCRIPTION

Rx Kcal 2800 kcal

CHO 420g, CHON 105g, Fats 80g

60% 15% 25%

DIET PRESCRIPTION: CHO 420g, CHON 105g, FATS 80g 2800kcal

FOOD LIST No. of exchanges CHO (g) CHON (g) Fat (g) Energy (kcal)

IA Veg A 8 12 (3) 4 (1) - 64 (16)

IB Veg B 7 21 (3) 7 (1) - 112 (16)

II Fruit 8 80 (10) - - 320 (40)

III Milk 1 12 (12) 8 (8) 5 (5) 125(125)

IV Sugar 4 20 (5) - - 80 (20)

Partial sum 145

420 (prescribed CHO)

- 145 ( partial sum CHO)

= 275/ 23 = 12 exchange rice

V Rice 12 276 (23) 24 (2) - 1200 (100)

Partial sum 43

105 (prescribed CHON)

- 43 (partial sum CHON)

= 62 / 8 = 8 exchange meat

VI Meat (LF) 8 - 64 (8) 16 (2) 400 (50)

Partial sum 21

80 (prescribed fat)

- 21 (partial sum fat)

= 59 / 5 = 11 exchange fat

VI Fat 11 - - 55 (5) 495 (45)

TOTAL 421 107 76 2796

A Days Exchanges Between Meals and Snacks

AM PM MN
Exchange group No. of exchange Breakfast Lunch Dinner
snack snack snack

Veg A 8 2 3 3

Veg B 7 2 3 3

Fruit 8 2 1 2 1 2

Milk 1 1

Sugar 4 1 2 1

Rice 12 2 2 2 2 2 2

Meat (Low Fat) 8 3 3 2

Fat 11 2 2 3 2 2

Breakfast

FOOD LIST EXCHANGE MENU

Veg A 2 1 cup spinach, cooked

Veg B 1 cup onion

Fruit 2 2 small apple

Milk 1 4 tbsp low fat or skimmed milk

Rice 2 4 pcs sliced bread

Meat 3 1 1/2 chicken breast

Fat 4 4 tbsps. French salad dressing

Chicken sandwich and diced apple with skimmed milk

AM Snack

FOOD LIST EXCHANGE MENU

Fruit 1 1 cup Strawberry

Sugar 1 1 pc Marshmallow

Rice 2 2 pcs ensaymada

Ensaymada and strawberry with marshmallow

Lunch

FOOD LIST EXCHANGE MENU

Veg A 3 1 1/2 cup sili leaves, sayote

Veg B 3 3 tbsps atsara (pickled papaya)

Fruit 2 8pcs grapes

Rice 2 1 cup rice, cooked

1/2 breast chicken

Meat 3
1 pc medium size grilled tilapia

Tinolang manok, Grilled tilapia with rice and atsara ,

grapes

PM Snack

FOOD LIST EXCHANGE MENU

Fruit 2 1/2 cup prune juice, unsweetened

Sugar 2 4 tsp condensed milk

Rice 2 2 pcs bread

Fat 4 2 medium size Avocado

Avocado and Toast with condensed milk, prune juice

Dinner

FOOD LIST EXCHANGE MENU

Veg A 3 1 1/2 cup Malunggay(dahon), cooked

1 cup Malunggay(bunga), cooked

Veg B 3
1/2 cup onion

Fruit 1 1 small Banana, lakatan

Rice 2 1 cup of rice, cooked

Meat 2 3 cups Tahong (Saltwater Mussels)

Fat 3 6 tsps peanut butter

Mussels with malunggay and banana with peanut butter

Midnight Snack
FOOD LIST EXCHANGE MENU

Sugar 1 2 tsp grape powder in a glass of water

Rice 2 2 pcs Hopiang Hapon, 5 cm diameter/pc

Hopiang Hapon and Grape juice