Health Disparities and

CARDIOVASCULAR
Disease Congestive
Heart Failure:
Clinical Scenario.
Najlaa Almohmadi
Dietetics Senior
December 3 , 2015

Agenda
Objective
Clinical Scenario
Health Disparity
Cardiovascular Disease
Pathophysiology of:
Hypertension (HTN)
Congestive Heart Failure(CHF)

Agenda
Nutrition Care PROCESS
Assessment
Diagnosis
Intervention
Monitoring & Evaluation

Barrier to change
Stages of Change
Summary/outcome

Objectives
Address the disparities associated with Cardiovascular
disease (CVD) and the major functions of the heart
Describe the pathophysiology of Congestive Heart Failure
(CHF)
Identification of the relationship between Hypertension
(HTN), Diabetes mellitus (DM), and Chronic Kidney
Disease (CKD).
Understanding the dietary implications involved in
Cardiovascular Disease (CVD).
Implement of Nutritional Care Process (NCP) in addressing
a patient with (CVD) disease and barrier to change

Clinical
Scenario

Clinical scenario
H.H is 43 Y/O Hispanic male admitted with
chest pain, legs swelling x 1 week and short of
breath (SOB), acute dyspnea, macrocytic
anemia , acute decompensated (CHF
secondary to cardiomyopathy. dilated
ascending aorta 4.5cm, mark cardiomegaly.
Hx, w/HTN,CHF with impaired ejection EF
37% , and GERD, alcohol and tobacco abuse.
His BP145/63 on 11/09. Skin intact. Patient is
non compliance to medications.. He is
physically inactive. He is currently employee
at restaurant. He is married with wife and

Health disparities
Racial and ethnic minority receive lower
quality
treatment, and experience worse health
outcomes than
their white counterparts
disparities are linked to a number of complex
factors such as
income
Education
genetic
access to care

Health disparities

Dramatic Health Disparities

among Hispanics in the U.S.
Representing 17% of the total U.S. population.
significant socioeconomic challenges.
have the lowest education among all races and
ethnicities in the U.S.
nearly three times more likely to lack health insurance.
face many types of stress related to discrimination.
less aware about heart disease, and if they have
certain risk factors for heart disease.
have higher rates of cardiovascular risk factors, such
as high cholesterol, diabetes and obesity.
less physically active
less likely to seek treatment and address these risk
factors.

Introduction
Cardiovascular disease CVD is the main
cause of death worldwide.
According to the CDC, each year
approximately 1 in every 4 deaths. (34.1%)
Half of those patients are over 60 years old.
D.C has the highest rank in the U.S
580 death in DC from heart disease, blood
pressure, and stroke in 2010.

Introduction
Over 50 percent of the deaths due to heart disease
were in men.
Coronary heart disease (CHD) is now the most
common type of heart disease, killing over 370,000
people.
Every year about 735,000 Americans have a heart
attack.
Deaths due to heart disease vary by race.
Heart disease is the leading cause of death for people
of major ethnicities in the United States Including
African Americans, Hispanics, Indians or Alaska
Natives and Pacific Islanders.

Introduction
CVD includes:
High blood pressure.
Atherosclerosis.
Coronary heart disease.
Peripheral Artery Disease
Ischemic Heart Disease
Heart failure.

Heart Functions
Closed loop of blood vessels
Regulates blood flow to tissues
Delivers oxygenated blood and nutrients
Retrieves waste products from cellular metabolism
Thermoregulation
Hormone transport
Maintenance of fluid volume
Gas exchange
Regulation of pH

How Our Blood Pressure Is

Regulated
Sympathetic nervous system
Renin-angiotensin system
Renal function
All three affect cardiac output
and consequently blood pressure

http://images.medicinenet.com/images/slideshow/low_blo
od_pressure_s9_signals_to_arterioles.jpg

Regulation of blood
pressure

Hypertension
Silent

killer

140/80 or 120/90 mm hg or normal

range with hypertensive medication.
Increases the risk for:
Congestive heart failure
Kidney failure
Myocardial infarction
Stroke
Aneurysms

Pathophysiology
Overload secretion of vasopressin and angiotensin:
leads to vasoconstriction and fluid and
sodium retention resulting escalation in blood
pressure.
Smoking:
impairing endothelial relaxation and
vasodilation by hinders nitrous oxide releasing
Renal disease:
can aggravate uncontrolled HTN due to
increase blood volume and vascular
resistance.
Adrenal disorders:

Etiology
Primary or essential:
Idiopathic (90% of the cases)

Secondary to another chronic

condition:
Renal disease and renal failure,
CVD
inflammatory response

Treatment
Decelerate risk of CVD and renal disease
Objective is to decrease BP to <140/80 or
<130/80
Treat through
Weight lose
adapt active lifestyle
nutrition therapy
Medication classes
Loop diuretics
Thiazides
Carbonic anhydrase inhibitions

Heart Failure
End-Stage CVD
results from the ventricle inability to pump blood and
supportive oxygen effectively to all organs of the body.
Almost 5.1 million Americans have heart failure.
Fifty percent of all people diagnosed with heart failure die
within 5 years.
The estimated cost of Heart failure on the American
government is $32 billion each year. (CDC 2014)

Causes and Pathophysiology

Causes:
prolonged uncontrolled hypertension:
Dilated cardiomyopathy
Valvular disease.
Pathophysiology:
begins with heart injury and blood pressure
changing (increases)
The heart struggles to keep up.
The heart adapts to this by thickening the muscles in
ventricles.
Health conditions progress

Heart Failure: causes and

Pathophysiology

Heart Failure: Clinical

Manifestations
Dyspnea,

fluid retention

fatigue

pulmonary retention

weakness

cardiac cachexia

poor adaptation to cold. edema

nutritional problem associated with and heart failure
include:
GI-slowed peristalsis
early satiety
poor nutrient absorption

Heart Failure: Treatment

Treat underlying causes and control
symptoms (HTN)
Medications
Exercise as tolerated
Nutrition Therapy

Risk Factors:
Alterable

unalterable

Poor diet

Family history

Smoking

Genetic

Obesity

Age

Physical inactivity
Diabetes
Dyslipidemia
High blood pressure

Other Diseases Related to

CHF
Diabetes mellitus
Patients with diabetes were much more likely
to develop CHF than patients without

Other Diseases Related to

CHF
Chronic Kidney Diseases
End stage renal disease ESRD is often
associated with the increases the HTN.
C-Reactive Protein CRP level is high in patient
with ESRD.
There is a high relationship between CRP and
atheroma formation, which leads to
atherosclerosis and coronary heart disease.
The study demonstrated that 57% of the ESRD
patients died of cardiovascular events.

Case Study- Methodology

Data was collected from:
Patients medical record(chart and sorian)
Interview with nursing and patient

Nutrition Care
Management

Nutrition Assessment- Past

Medical History
HTN
CHF with impaired ejection EF 37%
GERD
History off alcohol and tobacco abuse

Medications
Medication

Function

Side effect

Hydreloizon 50mg po q
8h

Antihypertensive
and CHF
treatment

Anorexia and increase

thirst

Lisinopril 5mg po qd

Antihypertensive

dehydration, low Ca
low Na

Lasix 40mg po q 12

Antidiuretic

dehydration, low Na

Lovenox 40 mg qd

Anticoagulant

Reduced renal function

Enoxaparin
(subcutaneous)

Anticoagulant

Reduced renal function

Aspirin 81mg po qd

Analgesic,
prevent platelet
aggregation

Dehydration, anorexia

Pantoprazole 40mg IV
q12 h

Anti- GERD

Reduced iron, B12, and

calcium absorption.

Physical Examination
Blood pressure 145/63 on 11/09

138/67 on 11/10

Skin intact, warm and dry

Anthropometric
Category

Measurement

Height

55 = 65 in 165.1 cm

weight

131.1 lbs / 59.59 kg

Admitted weight

142.9 lb due to edema.

PT gain 9%due to Edima142.9131.1/131.1x100 = 9%

BMI

59.59/ 2.72= 21.9Kg / m2 normal weight

IBW

136lbs +/- 10%

UBW

150

UBW% changes

150- 131.1/150 x 100= 12.6 %x 180 days

( significant weight loss)

Energy, Protein, and Fluid

needs
Category

Calculation

Mifflin

10( 59.51) + 6.25(165.1) 5(43) + 5 =

1418 kcal
Activities factor: 1.2= 1701 kcal
Stress factor 1.1 1.2 (high metabolic rate)
Total energy needs = 1871 2042 kcal

Protein

1.1- 1.2 g /kg ( hyper-metabolic rate)

Total protein needs = 66- 72 g protein/ day

Fluid

1200 mL ( fluid restricted)

Osmolality

287 mosm/ kg ( 280-295)

Diet History
Patient eats 1 to 2 meals per day. Skips
breakfast and lunch. Eat late dinner,
sometimes eats snacks once a day.
No food allergies/intolerances/dislikes
Current PO intake:100% plus snacks
Nurses mentioned that patient eats 100% of
his meal and asks for snacks

Biochemical Data
Basic
Metabolic
Panel

Normal
range

11/10 11/11

11/12

Sodium

135-148
mEq/L
3.55.0gm/dL
96-106
mEq/L

143

138

134

3.3

3.8

3.7

105

103

98

29

22

28

92

92

13

16

17

Potassium
clorid

25-32
mEq/L
70-115
mg/dL
Blood Urea 7-25
mg/dL
Nitrogen
(BUN)
Carbon
Dioxide
Glucose

Biochemical Data
Basic
Metabolic
Panel

Normal
range

Creatinine 0.6-1.2
mg/dL
Serum

11/10

11/11

11/12

0.9

1.1

1.1

Hgb

13.5-17.5 g/dL 11.7

13

13.7

HCT

38.8-50%

34.9

38.3

41.1

Total
cholesterol

< 200 mg/ dL

123

HDL

> 60 mg/ dL

30

LDL

< 100 mg/ dL

77

TG

< 200

160

Nutrition Diagnosis

Nutrition Diagnosis- PES

PES #1:
unintentional weight loss (NC-3.2) related to inadequate
protein and energy intake / low appetite secondary to CHF
as evidenced by weight loss % 12.6x 180 day (significant)
and patient stated that he ate from 1-2 meals l day
PES #2:
Impaired nutrient utilization(sodium and fluid)(NI-2.1)
related to diagnosis of CHF as evidenced by edema and leg
swelling and gain weight due edema 9%
PES #3:
Increase Nutrient needs (protein) related to metabolic
stress as evidenced by swelling leg and edema secondary
to CHF

Nutrition Intervention

Barriers
Patient is non compliance to medications
Socioeconomic issues
knowledge deficit about fluid restriction.

Stage of Change

Stages of Change
Pt is aware of the contemplation and willing to
change but doesnt know how.
He aware about his problem (Heart Failure
and fluid restriction), but does not know the
source of fluid like broth, jello, and popsicles.

Stage of Change
Counseling strategies:
Prepare patient about his heart failure
condition
Educate him about all options provided
( importance of taking medication, fluid
restriction and fluid resources, important of
eating small frequent meals)
Educate Pt about important of control his HTN
and use DASH diet.

PES #1: unintentional

weight loss
Goal: Maintain stable weight loss 131+/- 1-2 lbs
Intervention:
Diet Prescription: Cardiac diet, 2gm sodium diet
Education
Eat small frequent meals 5-6 per day
Increase physical activity as tolerated

Increase protein intake 1.1 to 1.2 to preserve protein (high

catabolic rate).
66- 72 g protein/ day
Ex fish ( Pt likes salmon) and chicken

PES#2 Impaired nutrient utilization(sodium and

fluid)(NI-2.1) related to diagnosis of CHF as
evidenced by edema and leg swelling and gain
weight due edema 9%
Goal: limit sodium intake <2000 mg/ day
Intervention:
cardiac diet 2 gm sodium :
Increase potassium, calcium, magnesium, and fiber
increase fruit and vegetable 5 serving a day
limit intake of red meat, processed meat, high-salt snacks,
canned food(unless stated low sodium).
Educate Pt about DASH:

PES#2 Impaired nutrient utilization(sodium and

fluid)(NI-2.1) related to diagnosis of CHF as
evidenced by edema and leg swelling and gain
weight due edema 9%
Goal: limit sodium intake <2000 mg/ day and Fluid restriction 1200 ml /
day
Diet:
Education
1200 mL fluid restriction = 5 cups
90 ml for nurses ( 30ml x 3) = 1/3 cup
1200-90 = 1110 ml = 4 2/3 cup 1110/ 3= 370 ml = 1.56 ~1 cup in
each meal
Note: broth, Jello, juices, and popsicles are considered fluid.

PES #3
Increase Nutrient needs (protein) related to
metabolic stress as evidenced by swelling
leg and edema secondary to CHF
Goal: increase protein intake 66-72 g protein/ day
Education
Increase protein intake: fish (Pt likes salmon) and chicken.
Soy
Bean

One day Manu

Breakfast
2 slices of whole
wheat bread
1 large egg white
(No fat)
2 table spoons
jelly. reduced
sugar
cup of milk.
(fat free)
cup
decaffeinated tea
or coffee with 2
tea spoon sugar
up water

lunch
2/3 cup of white rice
1 filet baked fish
cup of vegetables
soup (No meat)
1 cup of cooked
squash
1 cup of garden salad
(No salt added)
1 orange
cup decaffeinated
tea or coffee with 2
tea spoon sugar
cups of water

dinner
cup Leafy
green meatless
soup
2/3 cup of rice
and beans
cup green
beans
1 apple
cups of water

10;00 am
cup of
unroasted
almonds
1 cup plain
fat free
yogurt
dry
cranberries
HS
1 banana
cup Skim
milk

Fluid cup

Fluid 1 cups
Fluid 1 cups

snack

Fluid 1 cups

One day Manu: nutrient intake

Nutrient
Calories

Intake

Protein

81 g

Fluid

1 c( breakfast)+1 c (lunch) + 1c (dinner)+

c (snack)+ 1/3 c medications = < 5 c ( 5 cups)

Carbohydrate

251 g

Fiber

31 g

Fat

35 g 27% ( 25-30%)

Saturated fat

4% (<7%)

1823 calories (1800-2000)

(66-72)

Polyunsaturated Fat 7% Calories

Monounsaturated
15% Calories
Fat

cholesterol

82 mg ( <200 mg)

calcium

1435 mg (1000 mg)

sodium

1924 mg(<2000 mg)

potassium

4079 mg (4700 mg)

Nutrition
Monitoring and Evaluation

Monitoring and Evaluation

Indicator: Weight change
Criteria: prevent further weight loss (lean
muscle mass) or gain (edema) 133 lbs -/ +1-2
lbs

Indicator: Lab values

Criteria:, BNP, CMP

Skin:
breakdown skin

Coordination of Care
Financial support
Social work

Summary
It is critical that we address health disparities among
minority population
Hispanic and blacks have five fold risk for CVD- according to
CDC.
Nutritional intervention is critical to prevent and manage
CVD.
Medical nutritional therapy- as provided for the case study
Intervention /socioeconomic status
To eliminate health disparities among this population,
education, prevention, and treatment are the key.
Future goal is to decrease the health disparities among all
ethnic groups especially Hispanic
1

References
Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.).
Belmont, CA: Wadsworth, Cengage Learning.
Mahan, L., Escott-Stump, S., & Raymond, J. (2012). Krause's food & the
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Living Longer (October 2011)www.nia.nih.gov/research/publication/globalhealth-and-aging/living-longe. Updated January 22, 2015,
\Magorzewicz, S., Lichodziejewska-Niemirko, M., Aleksandrowicz-Wrona E,
wietlik D,, Rutkowski B, ysiak-Szydowska W. (2010). Adipokines
endothelial dysfunction and nutritional status in peritoneal dialysis patients.
Scandinavian Journal of Urology and Nephrology. 44(6):445-51. doi:
10.3109/00365599.2010.504191. Epub 2010
Heart Failure Fact Sheet, (July 22, 2014) http://
www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htm
Leon, B.M, and Maddox, T.M. (2015). Diabetes and cardiovascular disease:
Epidemiology, biological mechanisms, treatment recommendations and
future research. World Journal of Diabetes. Doi:10.4239/wjd.v6i13.1246

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Questions