Cardiovascular Disease: Case Study

Alyssa Specht
Carrie Hamady, MS, RD, LD
FN 4360 Life Cycle Nutrition: The Middle and Late Years
9 April 2014

Table of Contents
Introduction.................................................................................................................................................................3
Methods.........................................................................................................................................................................5
Results............................................................................................................................................................................6
Discussion..................................................................................................................................................................13
References.................................................................................................................................................................15

3
Introduction
Cardiovascular disease (CVD) is the number one leading cause of death in the
United States and worldwide.1 CVD has been defined as diseases related to the heart and
blood vessels and are usually associated with atherosclerosis.2 This is a broad definition
for several forms of CVD, notably coronary artery disease (Americas number one COD),
myocardial infarction (MI), and sudden cardiac death (the cause of half of all cardiac
deaths)3. Murmurs and arrhythmias are also forms of CVD, and although they are not
perceived as such, increase the risk of developing a more serious form of CVD as they are
indicative of abnormal heart function.4 Symptoms of CVD include shortness of breath,
angina, palpitations, weakness/fatigue, sweating, and nausea. 2
Extensive research has been conducted in an effort to better combat heart disease,
from a better understanding of how to target its etiology, to managing risk factors, to
understanding and preventing potential genetic manifestations. It has been supported
and established that several risk factors are at work in developing CVD: age, genetics,
gender, high cholesterol levels, weight status, activity level, diet, smoking status, and
other diseases.1,5 Age is perhaps the greatest uncontrollable indicator, primarily due to
the role of atherosclerosis (hardening of the arteries), a normal part of the aging process
that results in plaque buildup in the heart. Other factors may delay or accelerate this
process, but it is nevertheless inevitable.6 Most of the other risk factors can be
controlled to some degree by individuals, accounting for up to 90% of the likelihood of
developing CVD.1 In 2012, it was

4
discovered that there are 30 different genetic loci that affect genetic risk for CVD in the
human genome; however, these loci account for only 10% of total CVD risk. 1
The reinforcement of lifestyle factors being the primary cause of CVD has been
expounded by numerous studies on dietary factors, particularly fat sources and
polyphenols. A reduction in saturated and trans-saturated fat intake has been associated
with lower cholesterol.1 Other dietary sources identified in raising risk include red meat,
high-fat dairy products, and sugar-sweetened beverages; poultry, nuts, and fish have all
been associated with reducing risk. 1 Polyphenols reduce CVD via several biological
actions that are not fully understood. These compounds, which naturally occur in plants,
have immunomodulatory, vasodilatory, and antioxidant properties that work to reduce
inflammation in the body, an integral component of CVD as well as numerous other
diseases.1, 7 However, isolation of these compounds has not yielded the same results as
whole food sources: Intervention trials are needed using PP-rich foods to assess
whether typical intakes of such provided foods will result in cardioprotection.7
A more generalized assessment of different diet types and relation to CVD has
allowed for further insight of the effect of whole foods on CVD risk. The prudent diet,
Western diet, and Oriental diet were all compared in their ability to turn on interaction
between dietary components and genes that seem to have a cardioprotective role. The
prudent diet, high in raw fruits and vegetables, had the greatest level of gene activity,
and

5
the Western diet had the lowest gene activity.1 While research is ongoing, CVD can
certainly
be attributed to dietary intake, having an effect upon genetic interaction and
inflammatory processes. Essentially, diet as a whole is currently the best way to be
proactive against CVD; raising awareness of its significance in an aging population should
be of concern as these individuals are predispositioned to atherosclerosis, reduced
dietary intake, reduced physical activity, and other chronic diseases.6 For all individuals
at risk, current diet recommendations by the American Heart Association focus upon a
Mediterranean-style diet model, with high intakes of fruits, vegetables, whole grains, and
unrefined oils contrasted with low intakes of meats, sugar, refined grains, and saturated
fats.8
Methods
The pt. was a co-worker at a local grocery store, and was asked to participate if
willing based on the knowledge that she had had a heart attack in November of 2013. She
was informed ahead of time that she would need to bring with her to the interview a list
of her medications if possible and a three day food record. She was also informed that her
participation was completely voluntary and she did not need to answer any question if
uncomfortable. The interview took place in the grocery store after her she got off from
her work shift. The interview was directed via a set of questions as shown in Figure 1.

After the questions were answered, the three-day food record was then reviewed and
adjusted to obtain more details. The multiple pass method was utilized to observe any
missing or hidden foods or beverages.
After the completion of the interview, the diet was analyzed with SuperTracker
(available at https://www.supertracker.usda.gov/default.aspx). The average nutrient
and food group totals reports were then documented for further analysis of the pt.
6
Results
The pt. is an 84 yo female named Norma Burris. The interview questions provided
a framework for the interview, but answers led to derivatives of further questions (for
example, pt. did not know anything about her family history, and was not questioned
further). The interview questions were answered as follows in Figure 2.
Pt. was compliant with all of the interview questions, and continued to ask
additional questions about her lifestyle. Several details were included about her lifestyle
habits. Pt. lives alone and has never considered moving to an assisted living home,
although she expressed worry about living alone since her heart attack. She keeps
herself busy by working eight hour shifts four days per week at the grocery store. She
also is apart of a community group that does activities and dinners on occasion. She
regularly knits, weaves baskets, and other occasional crafts. She doesnt like to drink
anything at work because she does not want to use the bathroom and likes tea instead of
water. She doesnt like to cook much because she lives alone and thinks it is a hassle. She
does not like to eat much fruit and dislikes vegetables. She has little interest in changing

any habits now because of her age. Pt. also stated that she refused to have surgery for her
breast cancer because she didnt want to deal with it, also because of her age. She likes to
keep moving as much as she can and enjoys being with others.

7
Figure 1: Interview Guide

Figure 2: Answers to Interview Questions

Age (q1)

84 yo

Height (q1)

411 or 149.9cm

Weight; is this normal?

(q1)

91# (41.4kg) current body wt., usual body wt. btw.

103-105# (46.8-47.7kg). Has lost this weight since MI in
November 2013.

Last Dr. visit (q2)

2 weeks prior to interview visited oncologist; has had breast

cancer dx since early 2013.

What was the outcome?

(q2)

Discussion of treatment options for cancer; Dr. increased

dosage of meds from 1x/d to 2x/d. Discussed MI but was not
the point of the visit.

Health status/hx? (q3)

Has glaucoma, breast cancer, HTN. Not sure how long she has
had glaucoma but a few years, breast cancer for 1y, HTN for
5y. Used to smoke but quit 20 y ago. Also had breast
implants in 1975 and believes that may be the reason for her
breast cancer.

Medications? (q3)

Has several (Figure 3). Does not take any supplements except
for Vitamin D and a womens multivitamin, but was
prescribed by Dr.

Special diet? (q3)

Follows no special diet, eats whatever she wants. Doesnt like

a lot of foods that she used to like.

Family Health Hx? (q3)

Not sure; she is the only one left in her family. Had two
brothers that were alcoholics. Doesnt know of anyone else
having cardiovascular disease.

What happened when

you had the heart
attack? (q4)

Was at a community event dinner, felt very nauseous and

tired after the meal and felt pain underneath ribs. Vomited at
the dinner. Was driven to the ER by a friend. Vomited several
times at ER. Was determined that she had had an MI and
received 1 stent. Not sure where the stent was put in in her
heart.

What care did you

receive? (q4)

Was allowed to go home the next day and put on one heart
medication.

Any recommendations?
(q4)

Was told to not do anything that made her exhausted.

Received no dietary recommendations. Returned to work the
next day.

Any changes since your

heart attack? (q5)

Tastes have changed, and does not like a lot of foods anymore.
Tires more quickly, especially at work. Never used to sit
much in between activities, but now sometimes needs to rest
for an hour or two.

Diet/appetite? (q5)

Still eats foods is she likes them, but doesnt get much of an
appetite anymore.

Mood/Energy/Activity
? (q5)

Worries now sometimes about her health because she lives

alone and has no family.

Sleep? (q5)

Sleeps from 9pm to 4am, which is usual, but is now up every

two to three hours during the night.

Have you made any

changes since your
heart attack? (q6)

She rests a bit more, but has otherwise made no changes and
maintains her work and activity schedule.

Figure 3: Medications List

Medication

Dose

How Often

Reason

Hydrocodone

when needed

TMJ

Nitrostat

when needed

Chest pain

Lisinopril

1 x 20mg

1x/d

HTN

Metoprolol

1 x 50mg

1x/d

HTN

Sertraline

1 x 25mg

1x/d

Letrozole

1 x 2.5mg

1x/d

Breast cancer dx

Clonidine

every 8 hours

HTN dx

Atorvastatin

1 x 40mg

CVD dx

Effient

1 x 10mg

Blood thinner

low dose Crestor

Clopidogrel

1 x 75mg

1x/d

CVD dx
Blood thinner

Azopt

3x/d

Eye drops

Atenolol

2x/d

HTN dx

Latanoprost

1x/night time

Eye drops

1x/d

Glaucoma dx

Supplement
Glucosamine

1x 1000mg

Womens
multivitamin
Caltrate

1x/d
1 x 600

2/d

Ca and Vit D supplement

--Oncologist recommended

10
Figure 4: 3-Day Food Record
Day 1

Day2

Day 3

Breakfast -1 c. shredded mini

wheat
-3/4 c. whole milk
-1 mug coffee w/2 T.
whole milk

- 2 slices Pepperidge
Farm raisin toast w/2t.
butter
- 1 c. canned peaches
1 mug coffee w/2 T.
whole milk

- 2 slices Pepperidge
Farm stone rye bread
- 2 T. regular cream
cheese
- 1.5 t. jelly
- 1 mug coffee w/2T.
whole milk
- 1 small plain chicken
wing (deli made)

Lunch

- 6 triscuits
- 3 tsp. regular cream
cheese
-1 tsp. orange
marmalade

- 1/2 c. regular cottage

cheese
- 1/4 c. canned
pineapple
- 5 triscuits
- 4 Nabisco Lorna
Doone cookies

- 3 small plain chicken

wings (deli made)
- 1/4 c. coleslaw (deli
made)
- 4 Nabisco Lorna Doone
cookies

Dinner

-1 small bowl
goulash w/macaroni
noodles, hamburger,
and beans
-6 saltines w/3 t.
butter

- 4 small plain chicken

wings (deli made)
- 2 T. potato salad (deli
made)
- 1/2 Eskimo brand
chocolate ice cream bar

- 10 french fries (oven

baked)
- 3/4 lb steak (before
cooking)
- 1/2 tomato

Snacks

-1/2 Eskimo brand

chocolate ice cream
bar
- 2 glasses
unsweetened ice tea

- 2 glasses
unsweetened iced tea

- 1/2 Eskimo brand

chocolate ice cream bar
- 2 glasses unsweetened
iced tea

-1 glass
unsweetened iced
tea
- 1 chocolate turtle
candy

- 2 glasses
unsweetened iced tea
- 1/2 Eskimo brand
chocolate ice cream bar

- 2 glasses unsweetened
iced tea
- 1/2 Eskimo brand
chocolate ice cream bar

Measurements: - Coffee mug 8 oz.

- Iced tea glass 16 oz.
- Fist size = 1 c.
- Light bulb = 1/2 c.
- Pt. gave measurements for t., T., and brand name items

11
Figure 5: SuperTracker Food Group Totals Report

Target or Limit
5 oz.

2 cups

1.5 cups

3 cups

5 oz.

5 tsp.

.5 cups

.4 cups

.5 cups

5.3 oz

1.6 tsp.

Average Intake
4 oz

Figure 6: SuperTracker Nutrient Totals Report

12

Figure 7: Estimated Needs of the Pt.

Estimated

Actual

kcals/d

1600kcal/d

1323kcals

PRO

34-41g/d

67g/d

Fluids

1242 cc/d

1656 cc/d

BMI:

21.3 @ UBW 104#

18.6 @ CBW 91#

Weight change over 6

months

- 13lbs

13% wt. change: severe

13

Discussion
The results indicated that pt. status could be expected based off of medical
history, current diagnoses, and dietary recall. Although labs could not be provided, the
medication list was indicative of pt. health status. At 84 yo, pt. has multiple health issues,
all of which have age as a primary risk factor (CVD, breast cancer, HTN, glaucoma).
Symptoms of the MI that the pt. suffered were typical symptoms of fatigue, angina, and
nausea. Pt. history of smoking for 20 y, HTN for 5 y, and breast cancer for 1 y also placed
pt. at increased risk. However, prior to MI pt. had a normal BMI and led a relatively active
lifestyle, especially for her age.
The pt.s diet, however, was lacking in several nutrients and energy as evidenced
by the three day food record and nutrient reports in Figures 5 and 6. Figure 5 showed a
very low intake of fruits and vegetables and higher in animal protein sources that
included high-fat dairy, which has been evidenced as poor for cardiovascular health.
Figure 6 refuted the imbalance of the diet by inadequate intake of nutrients calcium,
magnesium, potassium, vitamins A, B6, C, D, E, K, thiamin, folate, alpha-linolenic and
linoleic fatty acids, dietary fiber, and carbohydrates. Pt. reporting side effects of a
decrease in appetite and taste changes as well as evidence of severe weight loss post MI
(Figure 7) are of concern. Overall, pt. was not following the recommended diet, but also
did not receive any recommendations from her doctors. Pt. stated at this point, she is not
planning on making any changes.
Pt. case was also complicated due to MI not being the primary health issue pt. is
dealing with at present. Although she states that HTN and glaucoma are under control,

her breast cancer is the primary concern. This can have several effects upon the body
that are
14
similar to CVD; one, or the other, or both could be the cause of the issues discussed above
(taste changes, for example).
Potential recommendations for the pt. would be to adopt a more fruit-and
vegetable- based diet and switch to lower fat dairy products to increase antioxidant
content and lower inflammation in an effort to prevent another attack. Pt. states that she
doesnt want to implement any changes simply because she hasnt noticed many changes
that she can attribute specifically to her MI. Pt. demonstrated understanding of the
imbalance of her diet but maintained eating what foods she still likes. For the pt.,
maintaining quality of life is her primary goal.

15
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4.

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6.

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8.

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