Transcript Heart Failure - Angela Wolfenberger

HMD 570 Summer 2014 Final Project
Presented by Angela Wolfenberger
Heart Failure Introduction
Definition, Etiology, and Diagnosis
 Symptoms
 Risk Factors and Public Health
Implications
 Complicating Factors
 Nutritional Significances
 Treatment Algorithm

Heart Failure: Definition
Heart Failure (HF) is a chronic, progressive, clinical
syndrome wherein the pumping action of the heart is
insufficient to meet the
metabolic demands of the
body. The heart muscle
enlarges, stiffens, and
weakens, resulting in
inefficient filling and pumping.
Blood flow is reduced, causing
Insufficient perfusion of organs
and extremities. Congestive
Heart Failure (CHF) is a type
of HF with pulmonary and peripheral (abdominal, leg/ankle)
edema. CHF and HF are often used interchangeably.
Heart Failure: Definition, cont’d
2 Types of Heart Failure:
Diastolic- The heart cannot fill
properly during the rest period;
preserved Ejection Fraction (EF)
Systolic- The weakened ventricle
cannot squeeze hard enough to
pump fluid properly; Decreased EF
Heart Failure generally results in:
 Cardiomegaly (enlarged heart)
 Increased Heart Rate
 Vasoconstriction
as the body attempts to compensate for the weakened heart tissue
Heart Failure: Definition- Stages
Stage
Definition
Stage A
Evidence of heart failure risk factors; no heart
disease, asymptomatic
Stage B
Heart disease present (structural changes);
asymptomatic
Stage C
Structural heart disease evident; symptoms
present
Stage D
Advanced heart disease; progressive HF
symptoms require aggressive medical therapy
Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure
Heart Failure: Etiology
What Causes Heart Failure?










Coronary Artery Disease (CAD)- Arteries narrow, decreasing blood flow to
heart
Myocardial Infarct (Heart attack)- One or more blocked coronary arteries,
heart muscle becomes damaged (cardiomyopathy)
Hypertension (HTN)- High blood pressure weakens heart muscle over time
Abnormal Heart Valves- Valves that don’t open/close properly disrupt blood
flow through heart, causing muscle to work harder
Arrhythmias- Abnormal heart rhythms or fibrillations damage heart muscle
Heart Defects- Abnormal heart structure can reduce muscle function
Pulmonary Disease- Fluid in lungs causes pulmonary hypertension, resulting
in enlarged left ventricle
Diabetes Mellitus (DM I or II)- High blood sugar weakens the heart muscle
Hypothyroidism- Low thyroid activity increases LDL cholesterol and
atherosclerosis
Drugs (ex. Cocaine, alcohol, etc.)-Dugs have various negative effects on the
heart muscle
Heart Failure: Diagnosis

How is Heart Failure diagnosed?
•
Elevated Brain Natriuretic Peptide (BNP) Blood Levels
Dyspnea-Shortness of breath
•
• Cheyne-Stokes Respiration- Periodic breaths
•
S3 Gallup- Extra heart sounds
Echocardiogram
•
•
•
•
Ventricular Ejection Fraction (LVEF) <45%
Chest X-ray- Showing Cardiomegaly
Edema-Peripheral (legs/ankles/feet), Abdominal, and Pulmonary
• Rales- Fluid sounds in lungs, wheezing, coughing
• Hepatomegaly- Fluid retention causes liver swelling
• Stasis Dermatitis-Peripheral swelling causes epidermal tissue breakdown
*No single test can diagnose heart failure
Heart Failure: Symptoms
 What











are the Symptoms of HF?
Dyspnea (shortness of breath), especially when supine
Edema (swelling of ankles/legs/feet, abdomen, lungs)
Fatigue
Cough (dry, hacking, unproductive)
Nausea, anorexia
Syncope
Sudden weight gain (>3 lbs./day or 5 lbs./week)
Angina
Elevated heart rate and/or blood pressure
Anxiety, confusion, decreased alertness
Nocturia (need to urinate at night)
Heart Failure Symptoms, cont’d
Heart Failure: Symptoms, cont’d
Stages of HF:
NYHA Class I:
Asymptomatic; patient is not short of breath or
fatigued with any activity
NYHA Class II:
Patient is short of breath or fatigued after
moderate activity (such as climbing two flights
of stairs, golfing nine holes, or carrying a load of
wash up from the basement)
NYHA Class III:
Patient is short of breath or fatigued even after
very mild exertion (such as walking around the
house or up half a flight of stairs)
NYHA Class IV:
Patient is exhausted, short of breath, or fatigued
at rest (just sitting still or lying in bed).
 New York Heart Association Functional Classification (NYHA)
Heart Failure: Risk Factors

CAD (75% of HF is caused by CAD)

HTN (2nd leading cause of HF)

Myocardial Infarct

Diabetes Mellitus (DM I or II)

Some diabetes medications


rosiglitazone [Avandia]
pioglitazone [Actos]

Sleep Apnea- Improper breathing while asleep decrease blood oxygen levels
and increases risk of abnormal heart rhythms.

Congenital heart defects, Arrhythmias

Viruses- Some viral infections damage heart muscle.

Alcohol/Drug Use
Heart Failure: Public Health Implications
5.8 Million Americans suffer from HF
 2.8% of the general population (2010),
 Will rise to 3.5% by 2030
 10% of people >65 years old (2010)
1 in 5 adults over 40 will suffer from HF in their lifetime
400,000+ new cases of HF each year in the US
1 in 5 HF patients die in 1 year, 50% die within 5 years
Major HF risk factors are rising each year:
 Diabetes
 Obesity
 Aging Population
HF costs $24.7 Billion per year (2010), and is projected to
escalate to $77.7 Billion by 2030
Heart Failure: Complicating Factors

Kidney Damage/Failure- HF reduces blood flow to
kidneys, which can cause kidney failure. Some HF medications can
cause kidney damage.

Heart Valve Damage- Valves may not function properly if
heart is enlarged, or if the pressure inside the heart is very high.

Liver Damage- HF can cause abdominal edema, putting
pressure on the liver, causing scarring.

Stroke- Blood flow in HF through the heart is slower than normal,
making blood clots more likely.
Heart Failure: Nutritional Significance
• Restrict Sodium Intake to <2000mg/day (about 1 teaspoon)
• Sodium causes fluid retention and increased blood pressure
• Restrict Fat Intake, Especially Saturated Fats (if hyperlipidemia is
involved)
• 30% of daily Kcal should come from fats, >10% from Sat fats
• Modify Fluid Intake• Restrict fluids to <1.5 Liters, because of fluid
retention/edema
• Consume Adequate Protein
• 1.12-1.37g protein/kg of weight per day may be
necessary to prevent cachexia (wasting) in HF
• Micronutrients- Some HF medications cause
accumulation or depletion of essential minerals like K, Mg,
and/or Ca
• Taking a daily Multi-vitamin/Multi-mineral supplement
may ameliorate the effect of medications
Heart Failure: Drug Therapy Algorithm
Heart Failure
Case Study:
Joseph Himm
•
•
•
•
•
•
Patient Information
Patient History
Symptoms
Risk Factors
Diet (24-hour Recall)
Lab Values
HF Case Study:
Joseph Himm,
Patient Information
Age: 79 years
 Height: 65”
 Weight: 209 lbs.
 BMI: 34.8, obese (class I)









Normal weight range (BMI 18.5—24.9) is 110 to 149 lbs.
Blood Pressure: 119/71 mmHg (without medication: 220/170 mmHg
or higher)
Pulse: 60 bpm
LVEF: 27% (normal=55-70%, HF<45%)
Diagnosis: NYHA Class III Heart Failure
Medications: Lasix (120mg/d), Nitroglycerin (.4mg/prn), Carvedilol
(25mg/d), Allopurinol (300mg/d), Ramipril (5 mg/d), Plavix (75 mg/d),
Isocitrate (90 mg/d)
Caucasian
Physical Activity: No exercise tolerance
HF Case Study:
Joseph Himm,
Patient History
Mr. Himm was diagnosed with HTN in 1972, and has taken medication to control his
blood pressure since that time. Mr. Himm suffered an MI in 1982, and another in 1994.
He also suffered a CVA (stroke) in 1997, and another in 1999. He has suffered many
TIAs (transient ischemic attacks). Mr. Himm had coronary bypass surgery (CABG) with
4 bypasses, (5th blockage could not be bypassed) in 2002, with Carotid Endarterectomy
(CEA) at the same time. He had an Implantable Cardioverter Defibrillator (ICD)
implanted in 2012. He has had multiple heart catheterizations over the years.
Mr. Himm was an athlete in his youth, but has led a sedentary lifestyle for the last 45
years.
Mr. Himm was counseled about the DASH diet (Dietary Approaches to Stop
Hypertension) by his cardiologist upon his initial HTN diagnosis. He stopped cooking
with added salt and adding salt to cooked foods at that time (as did his wife). His diet is
otherwise uncontrolled, and he has weighed in excess of 200 lbs. for 15+ years.
Mr. Himm has difficulty with ADLs (dressing, shaving) because of CVA damage, so he
leaves the house infrequently. He sits and watches television for the large part of each
day. He also does not like to leave the house because of urinary incontinence fears from
his Lasix (diuretic).
Mr. Himm has had difficulty sleeping for many years, and takes naps throughout the day
and night. He does not sleep for more than 2-3 hours at a time.
Mr. Himm’s father died of MI in 1945, at age 45 years.
HF Case Study:









Joseph Himm,
Symptoms
Angina upon rising and with any effort (stairs,
walking, lifting, etc.)
Dyspnea with any physical activity (limits activity due
to dyspnea and angina)
Edema in legs, ankles, feet, and abdomen
Stasis Dermatitis in lower legs
Nocturia (2x/night)
Bradycardia (pacemaker controlled)
Memory and Speech deficit, occasional confusion,
and anxiety
Bowel Movements loose, 3-4x/day
Sleep Apnea
HF Case Study:






Joseph Himm,
Risk Factors
Age- Mr. Himm’s HF risk is exacerbated by his advanced age (79
years). 8% of men in this age group have HF.
Obesity- Mr. Himm’s BMI is 34.8. Some of his weight can be
attributed to water retention, but his wife states that his weight does
not decrease more than 2-3 pounds when he takes Lasix.
Unhealthy diet- Mr. Himm consumes many processed foods at
meals and snacks, which have high saturated fat and salt content.
He consumes few vegetable-especially green leafy vegetables. He
consumes too little fiber.
Genetic Predisposition- Mr. Himm’s father died at age 45 from
CVD (cardiovascular disease).
Anxiety- Mr. Himm suffers from anxiety and mental confusion.
The stress puts significant strain on his heart, and he occasionally
forgets to take his medications.
LVEF- Mr. Himm is in danger of sudden cardiac death from
ventricular fibrillation due to his low ejection fraction (27%).
HF Case Study:
Joseph Himm,
Diet- 24 Hour Recall
Breakfast
Lunch
Dinner
Snacks
1 c. Rice Crispies
Cereal with ½ c.
Frozen Blackberries
Toasted Sandwich
with 2 slices
Whitewheat bread, 1
slice Sargento Swiss
Cheese, 1 Slice
Sargento Cheddar
Cheese, 2 fresh
tomato slices, 2 tsp.
honey mustard
1 skinless, boneless
chicken breast, 1.5 c.
egg noodles, 3/4 c.
jarred Alfredo sauce
1 med. Peach
1 c. 2% milk
1 c. hot tea
1 c. sea salt/vinegar
potato chips
8 oz. coffee
1 tsp. sugar
1 Brown Cow ice
cream stick
2 tsp. sugar
2 c. fresh water
melon
HF Case Study:
Joseph Himm,
Diet- 24 Hour Recall, cont’d
Analysis
HF Case Study:
Joseph Himm,
Diet- 24 Hour Recall, cont’d
Analysis, cont’d








Kcal- 2161
Sat Fat- 66g (limit 22g)
CHO- 215g (AI 100g)
Fiber- 16g (target 25g)
Ca- 1283mg (RDA 1200mg)
K-2035mg (AI 4700mg)
Mg-252mg (RDA 420mg)
Na- 2475mg (AI 1200mg)
Empty Calories- 839 Kcal
PRO- 84g (AI for HF 75.68g)
Vit. C -43mg (RDA 90mg)
Vit. D-15ug (RDA 20ug)
Vit. K- 43ug (AI 120ug)
Vit. E- 8mg (RDA15mg)
Mr. Himm consumed adequate amounts of other vitamins and
minerals
HF Case Study:
Joseph Himm,
Significant Lab Values
Test
Normal Value
Mr. Himm’s Value
Significance
BUN
8-27mg/dL
23mg/dL
Kidney function
Creatinine, Serum
.76-1.27mg/dL
1.77mg/dL (High)
Kidney function
eGFR
>59mL/min
36mL/min
Kidney filtering efficiency
Sodium, Serum
134-144mmol/L
140mmol/L (Normal)
High Na occurs with water
retention, can cause mental
/heart impairment
Potassium, Serum
3.5-5.2 mmol/L
5 mmol/L
(Normal)
Diuretics can lower K, ACE
inhibitors can raise it
Calcium, Serum
8.6-10.2 mg/dL
9.0 mg/dL
(Normal)
AST
0-40 IU/L
17 IU/L
(Normal)
>40 indicates liver damage
ALT
0-44 IU/L
11 IU/L
(Normal)
>44 indicates liver damage
LDL Cholesterol
<130mg/dL
128 mg/dL
(Normal)
Elevated LDL increases risk
of CVA/MI
HDL Cholesterol
>45mg/dL
66 mg/dL
(Normal)
102mg/dL
(Normal)
97mg/dL
(Normal)
Triglycerides
Glucose, Serum
65-99 mg/dL
(Normal)
(Low)
Elevated serum Glucose
increases risk of
complications in HF
Relevance to Mr. Himm
EAL Guidelines
Topic
Research Studies
Rating/Relevance
to Mr. Himm
Referral to an RD for Medical
Nutrition Therapy (MNT) can lead
to better quality of life (QOL) with
less edema and fatigue, and
hospitalizations. One 45min
session + 3 or more 30 min followup sessions are required.
A 3-year longitudinal study of RD-provided MNT for
HF patients found that an initial 45 min visit and 23 follow-up 30 min visits conveyed meaningful
decreases in Na/fluid intakes and improved QOL,
and decreased hospitalizations. A different RCT of
RD-delivered MNT for HF patients found sodium
intake was reduced.
1 RCT on the impact of nutrition education by an
RD found decreases in Na/fluid intake.
Strong/Imperative, Grade II
HF patients have higher protein
needs than normal. Stable,
depleted patients should consume
at least 1.37 g protein/kg and
normally nourished patients should
consume 1.12 g protein/kg to
preserve body composition/ limit
hyper catabolism.
2 cross-sectional studies reported that patients with
HF have significantly higher protein needs
(measured by negative nitrogen balance). 1 study
showed minimum daily intake of 1.37 g protein/kg
for (stable depleted), and daily intake of 1.12 g
protein/kg for normally nourished HF may preserve
body comp or limit hyper catabolism. Be cautious of
fluid levels with decompensated patients and
interpretation of albumin and renal insufficiency.
Excess fluid may overestimate calorie needs,
causing albumin levels to appear lower than factual.
Diuretics/fluid restriction may influence renal
insufficiency, so limiting protein may not be justified.
Fair/Imperative, Grade III
EAL Guidelines
Protein Needs
HF
MNT
HF
Nutrition Assessment
Mr. Himm is obese, has
edema, fatigue, and no
exercise tolerance.
Mr. Himm’s HF puts him at
risk of hyper catabolism, so
he should consume 1.12g
protein/kg/day, not the
.66/kg/day normally
recommended for his age.
EAL Guidelines
Topic
Research Studies
Rating/Relevance
to Mr. Himm
Studies show indirect calorimetry
best determines energy needs
Use predictive equations when
necessary, adjusting for catabolic
needs.
5 studies addressed the Kcal/ protein needs in
clinically stable HF at all BMIs. 1 high-quality study
showed HF patients had higher REE and TEE vs.
controls. 1 neutral-quality study found HF patients
had higher REE vs. controls. 1 high-quality study
showed that REE and DEE were lower in cachectic
HF patients vs. noncachetic HF patients and
controls. 1 high-quality study found HF patients had
lower DEE vs. controls. Predictive equations
developed from healthy controls inaccurately
measured energy needs in HF by-10 to 30%. 1
neutral-quality study found predictive equations
underestimated energy needs in HF by 2-11%.2
studies found that equations designed for healthy
subjects either over- or underestimated needs
in HF patients. 2 studies suggest extreme caution
when prescribing hypo caloric diets in
overweight/obese HF patients.
Fair/Imperative, Grade III
Assess food/nutrient-medication
interactions in patients on
pharmacologic therapy for HTN.
Many antihypertensives react with
food/nutrients.
The JNC 7 report found that BP control can be
achieved for most with HTN, though many need 2+
antihypertensive meds. The JNC 7 report found
that failing to take antihypertensives and to modify
lifestyle may cause failure of BP control. Adverse
side effects and drug-nutrient interactions may
occur in some HTN patients on antihypertensive
therapy.
Consensus/Imperative, no
Grade
EAL Guidelines
Food/Nutrient
and Medication
Interaction
Assessment
HTN
Energy Needs
HF
Nutrition Assessment, cont’d
Mr. Himm consumes
excess energy, as
evidenced by his BMI
(34.8).
Mr. Himm is medicated for
HTN. His ACE inhibitors
and diuretics for HF also
interact with K.
EAL Guidelines
Topic
Research Studies
Rating/Relevance
to Mr. Himm
Sodium (Na) intake <2000 mg (2 g)/day
improves symptoms (edema, fatigue,
etc.) and QOL.
Limited available
evidence supports 2,000-mg/day Na
diet and 1.5L/day fluid restriction. 1
RCT (small sample size/short
duration) showed tolerance for Na
range of 1,610mg/day -5,750mg/day
for compensated medically-treated
HF.
Fair/Imperative, Grade II
Fluid intake should be <2 Liters/day for
HF patients with edema and dyspnea,
Fluid restriction improves symptoms
and QOL.
4 studies found Na
restriction with/without fluid restriction
ameliorated 1+ of: QOL, NYHA class,
sleep disturbance, physical activity,
edema, BNP and blood pressure. A
possible risk of fluid/Na restriction is
increased BUN/Creatinine
(hypovolemic). Modification of
diuretics, fluid and Na intake should be
considered.
Fair/Imperative, Grade II
HF patients should take A multivitamin/mineral containing B12 or a
combo of B6, B12 and folate. B12
supplements (200-500 mcg/day), along
with other vitamins/minerals, may
improve HF outcomes.
2 positive-quality (small sample size,
short duration) studies showed
improvement of HF when folic acid
was given as part of a
multivitamin/mineral or with B12 and
B6.
Fair/Imperative, Grade II
EAL Guidelines
HF
B12
Fluid Intake
HF
Sodium
Intake
HF
Nutrition Intervention
Mr. Himm is consumes
excessive sodium. Limiting
Na will ameliorate his
symptoms.
Mr. Himm suffers from
dyspnea with activity and
peripheral edema. Fluid
restriction may benefit his
condition.
Mr. Himm’s consume few
vegetables (especially
greens), so a multivitamin
with B-vitamins may
improve his condition.
EAL Guidelines
Topic
Research Studies
Rating/Relevance
to Mr. Himm
Dietary Approaches to Stop
Hypertension (DASH) diet contains
fruits, vegetables, low-fat dairy, and nuts
and is low in sodium, total fat, and
saturated fat.
The JNC 7 report revealed that lifestyle
modifications reduce BP, prevent/delay
HTN, enhance antihypertensive drug
efficacy, and lower CVD risk. The JNC
7 report found that BP is reduced (8 14 mmHg) by using the (DASH)
dietary pattern, and a 1600 mg Na
DASH diet has BP effects similar to
single drug therapy (in some patients).
Combining 2+ lifestyle modifications
achieves superior results.
Consensus/Imperative, no
Grade
Patients should engage in physical
activity (PA) 30 min/day.
The JNC 7 report stated that all
individuals should engage in aerobic
PA for 30+min/day (most days of the
week) which may lower systolic BP
by 4 - 9 mmHg. Physician approval is
required before embarking on any
exercise program.
Consensus/Imperative, no
Grade
The JNC 7 report found weight loss of
10+ lbs. (4.5 kg) reduced BP and/or
prevented HTN in many overweight
persons.
Consensus/Imperative, no
Grade
EAL Guidelines
HTN
Management
Weight
Physical
Activity
HTN
DASH Diet
HTN
Nutrition Intervention, cont’d
Patient should attain normal body weight
(with BMI 18.5 - 24.9) which will reduce
blood pressure.
Mr. Himm also suffers from
HTN and is Obese. The
DASH diet is low-fat and
restricts Na, which is
appropriate for this HF
patient.
Mr. Himm is completely
sedentary. Some PA would
alleviate symptoms and
lower his BP.
Mr. Himm is obese (BMI
34.8). Attaining normal
BMI/weight would favorably
impact his condition.
EAL Guidelines
Topic
EAL Guidelines
Research Studies
Rating/Relevance
to Mr. Himm
5 of 6 RCTs (4 weeks-6 months
duration) reported meaningful
decreases in BP with 5-10
servings of fruits/vegetables per
day). 1 cohort study and 2 crosssectional studies associated
increased fruit and vegetable
consumption with reduction in BP
Strong/Imperative, Grade I
Fruits and Vegetables
HTN
Nutrition Intervention, cont’d
Consume at least 5-10 servings of fruits
and vegetables per day. Research
shows meaningful decrease in BP when
following DASH diet or diet rich in
fruits/vegetables.
Mr. Himm consumes sub
par amounts of vegetables
(and possibly fruit).
Adequate intake would
positively impact his
condition.
Mr. Himm has adequate blood levels of Mg, Ca, and K, so the correlating guidelines
do not apply at this time. His blood chemistry should be monitored and guidelines
Implemented as necessary (if serum levels fall). Mr. Himm does not consume alcohol,
so the corresponding guideline does not apply. Mr. Himm does not like taking a lot of pills,
So additional bionutrient therapy (per guidelines) is not supported at this time.
Joseph Himm
SOAP: Joseph Himm
 S:
Mr. Himm reports long Hx of HTN, and CAD, with multiple coronary artery bypass,
carotid endarterectomy, 2 MIs and 3 CVAs. Patient suffers dyspnea with walking, stairs,
lifting, etc. Patient consume high fat, high energy, high salt diet (per 24-hour recall). He
reports taking his medications sporadically in the past, but regularly now that he feels poorly
(fatigue, angina, edema, dyspnea). Patient has been obese for approx. 15 years and
tolerates no physical activity. Patient suffers anxiety, periodic mental confusion, slow
speech, and muscle weakness (from previous CVAs). Father died at age 45 of MI (1945).
 O: Age: 79 years, Ht: 65”
Wt.: 209# BMI: 34.8 BMI Class: Obese, Class I
Dx: Cardiomyopathy (425.1), Edema (782.3), Stable Angina (412.9), Carotid Stenosis
(433.1), Heart Failure (428.0)
BP (unmedicated): 220/170, BP (medicated): 119/71 Pulse: 60 (with pacemaker working
3-7%).
Medications: Lasix (120mg/d), Nitroglycerin (.4mg/prn), Carvedilol (25mg/d),
Allopurinol (300mg/d), Ramipril (5 mg/d), Plavix (75 mg/d), Isocitrate (90 mg/d)
SOAP, cont’d: Joseph Himm

A:
NI-1.3 Excessive Energy Intake related to Kcal/ fat/CHO consumption above TEE as evidenced by BMI of
34.8 (obese, class I) and 24 hour diet recall
NB-2.1 Physical Inactivity related to sedentary lifestyle and heart failure as evidenced by exercise
intolerance, excessive TV. watching, and obese BMI.
NB-1.1 Food-and Nutrition-Related Knowledge Deficit related to excessive in take of saturated fat
and salt as evidenced by24-hour food recall, edema, and adiposity whilst claiming to follow a DASH
dietary pattern.
 P:
Intervention ND-1 Meals and Snacks. Pt. to follow DASH dietary pattern to decrease salt and saturated fat
intake and increase fruit and vegetable intake. Pt. to receive printout of DASH guidelines to post in kitchen
E-1 Nutrition Education. Pt. will learn to read labels to avoid processed foods with high salt and
saturated fat content. Use cognitive behavior theory to instruct Pt. to prepare and include fruits and
vegetables in meals and snacks
Monitor/Evaluate: F-1.1 Energy Intake.
Pt. will keep food log.
BE-1.1 Beliefs/Attitudes. Monitor actual fat/salt/energy/vegetable intake vs. Pt. perceived intake
S-1.4 Weight/Weight Change Follow up with Pt. weight/BMI
S2.3 Creatinine. Monitor Pt. Lab Values to ensure diet maximizes HF/renal outcomes.
Treatment Plan: Joseph Himm
After our initial 45-minute consultation, Mr. Himm will embark on a lifestyle
modification plan to include healthy eating (and keeping a food diary), body weight/BMI
reduction and increased Physical Activity.
Dietary changes will include: (5-10 servings/day) of fruits and vegetables
(emphasis on variety and color), daily multivitamin to maintain to comply with
recommendation for Folate, Thiamin, B6, B12, Ca, Mg, and Potassium (K). Lab values
will be monitored on subsequent visits to ensure adequate intake. Diet will consist of
low-Na, Low-fat DASH style dietary pattern to lower BP and ameliorate HTN, lower
edema, and maintain cardiovascular integrity. The diet will include 1.12g/kg/day of
Protein, <30% Fat with <10% Sat Fat,<100-130g CHO, <2000mg Na, and <1.4-1.9L
of fluids. Fiber levels will be monitored and adjusted as necessary due to Mr. Himm’s
report of frequent, loose stools. Mr. Himm’s therapeutic prescriptions and lab values
will be monitored to ensure no or food/nutrient-drug interactions. For example, Mr.
Himm’s diuretics lower serum Potassium while his ACE-inhibitors raise serum
Potassium levels. Kcal content of food will be adjusted and monitored to support
weight loss while conserving muscle and preserving body composition as indicated for
HF.
I will suggest that Mr. Himm attempt to decrease TV. watching while increasing
physical activity as recommended by his physician for his ability.
I will schedule at least 3 monthly 30 minute follow-up visits to evaluate Mr.
Himm’s food/nutrient intake based on his Food Diary, and lab values (to include
Creatinine/BUN, eGFR, serum mineral levels, serum lipids, glucose, etc.), and to
monitor and support his continued healthy diet and physically active lifestyle.
Sample Menu: Joseph Himm
Breakfast
Mid-Morning
Snack
Lunch
Mid-Afternoon
Snack
Dinner
1 cup Shredded Wheat
½ cup sliced
strawberries
1 grilled Chicken
Breast Sandwich
(whole wheat bun) with
sliced tomato, lettuce,
and lo-Cal honey
mustard
6 oz fruit yogurt, fat
free
3 oz broiled Flounder
with lemon pepper Mrs.
DASH seasoning
1 cup non-Fat Milk
1 cup sugar free
flavored jello
½ cup Sliced
Cucumbers
1 oz. almonds,
unsalted
1 cup mixed green
salad with low sodium
low-fat dressing
1 med. banana
1 Tbsp. light whipped
cream
½ cup carrot sticks
1 med pear
1 cup brown rice,
cooked with low
sodium chicken broth
8 oz Coffee with
Splenda
½ cup sliced celery
1 oz whole wheat
dinner roll with 1 tsp.
margarine
1 piece of Whole
Wheat Toast with 1 tsp.
margarine
3 Tbsp. home-made
non-fat ranch dip
½ steamed broccoli
with 1 tsp. margarine
EAL: Lessons Learned
I have thoroughly enjoyed becoming familiar with the Evidence Analysis Library this
Semester. I love to research topics of interest, especially in nutrition and preventive medicine.
The EAL is a handy reference for current knowledge about common health conditions and their
nutrition implications. I now feel comfortable looking up guidelines for dietary treatments, and feel
confident that the material that I am reading comes from thoughtful analysis of peer-reviewed
literature. I especially appreciate the information about the quality and amount of research behind
each guideline, together with the ratings and grades. I also feel that the knowledge I glean from
the EAL will help me with interview questions when I apply for internships next year.
The EAL also helps the practitioner understand the importance of motivational
interviewing. There were many guidelines for Heart Failure that I was unsure whether they were
applicable until I spoke at length with the subject (Mr. Himm). I asked him questions, then I read
through the EAL guidelines, and I thought of many more questions to ask. This helped me gain a
far deeper understanding of his diagnosis, symptoms, etc.
The news media is filled with “sound bytes” and fad diet “factoids” with little, if any,
scientific basis. The EAL helps me separate fact from fiction quickly and efficiently, which will not
only be of great use in my future practice, but is very informative for me as a dietetics student,
since I constantly field questions from friends and family concerning nutrition “information” in the
media.
Finally, I am studying dietetics as a second career. I am am following my passion while,
hopefully, contributing to society. My first career has provided me with enough disposable income
that I can pursue whatever field of dietetics I desire without worrying about supporting my family
with the income. I think that I would enjoy participating in the analysis for future EAL topics, as I
love scouring peer-reviewed articles for information about interesting topics. What an exciting way
to contribute to the future of the profession!
Bibliography:










Academy of Nutrition and Dietetics Evidence Analysis Library. (2008). Heart Failure Guideline.
Retrieved July 24, 2014 from http://www.andeal.org/topic.cfm?menu=5289&cat=3249
Academy of Nutrition and Dietetics Evidence Analysis Library. (2008). Hypertension Guideline.
Retrieved July 27, 2014 from http://andevidencelibrary.com/topic.cfm?cat=3248
American Heart Association (2014). Heart Failure, Retrieved July 24 from
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/About-HeartFailure_UCM_002044_Article.jsp
Amirkalali, B., Hosseini, S., Heshmat, R., & Larijani, B. (2008). Comparison of harris benedict
and Mifflin-ST Jeor equations with indirect calorimetry in evaluating resting energy expenditure.
Indian journal of medical sciences, 62, 283. doi: 10.4103/0019-5359.42024
Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo Jr, J. L., ... &
National High Blood Pressure Education Program Coordinating Committee. (2003). The seventh
report of the joint national committee on prevention, detection, evaluation, and treatment of high
blood pressure: the JNC 7 report. Jama, 289, 2560-2571. doi:10.1001/jama.289.19.2560
Institute of Medicine (2014). Dietary Reference Intakes,, Retrieved July 28, 2014
from http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/
Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf
Mayo Clinic (2014). Heart Failure, Retrieved July 24, 2014 from
http://www.mayoclinic.org/diseases-conditions/heart-failure/basics/definition/con-20029801.
National Heart, Lung, and Blood Institute (2014). Heart Failure. Retrieved July 24, 2014 from
http://www.nhlbi.nih.gov/health/health-topics/topics/hf/
Shamsham, F., & Mitchell, J. (2000). Essentials of the diagnosis of heart failure. American
Family Physician, 61(5), 1319-1330.
USDA (2014). SuperTracker. Retrieved July 28, 2014 from
https://www.supertracker.usda.gov/foodtracker.aspx
Addendum: Patient Education Materials: Allegheny Gen’l Hospital,
Pittsburgh, PA.