HEART FAILUREA CASE STUDY

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 (HF) is a chronic, progressive, clinical syndrome wherein the pumping action of the heart is insufficient to meet themetabolic demands of the body. The heart muscle enlarges, stiffens, and weakens, resulting ininefficient filling and pumping. Blood flow is reduced, causingInsufficient perfusion of organsand extremities. CongestiveHeart 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

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 HFsymptoms require aggressive medical therapy

Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure

Heart Failure: EtiologyWhat 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 lifetime400,000+ new cases of HF each year in the US1 in 5 HF patients die in 1 year, 50% die within 5 yearsMajor 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 Snacks1 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 Empty Calories- 839 Kcal Sat Fat- 66g (limit 22g) PRO- 84g (AI for HF 75.68g) CHO- 215g (AI 100g) Fiber- 16g (target 25g) Ca- 1283mg (RDA 1200mg) Vit. C -43mg (RDA 90mg) K-2035mg (AI 4700mg) Vit. D-15ug (RDA 20ug) Mg-252mg (RDA 420mg) Vit. K- 43ug (AI 120ug) Na- 2475mg (AI 1200mg) 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 SignificanceBUN 8-27mg/dL 23mg/dL (Normal) Kidney function

Creatinine, Serum .76-1.27mg/dL 1.77mg/dL (High) Kidney function

eGFR >59mL/min 36mL/min (Low) 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)

Triglycerides 102mg/dL (Normal)

Glucose, Serum 65-99 mg/dL 97mg/dL (Normal) Elevated serum Glucose increases risk of complications in HF

EAL: Guidelines and Supporting Evidence

Relevance to Mr. Himm

EAL Guidelines

Topic EAL Guidelines Research Studies Rating/Relevance to Mr. Himm

Nutrition Assessment

MNTHF

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 follow-up sessions are required.

A 3-year longitudinal study of RD-provided MNT for HF patients found that an initial 45 min visit and 2-3 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

Mr. Himm is obese, has edema, fatigue, and no exercise tolerance.

Protein

NeedsHF

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

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 EAL Guidelines Research Studies Rating/Relevance to Mr. Himm

Nutrition Assessment, cont’d

Energy Needs

HF

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

Mr. Himm consumes excess energy, as evidenced by his BMI (34.8).

Food/Nutrient and

Medication Interaction

AssessmentHTN

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

Mr. Himm is medicated for HTN. His ACE inhibitors and diuretics for HF also interact with K.

EAL Guidelines

Topic EAL Guidelines Research Studies Rating/Relevance to Mr. Himm

Nutrition Intervention

Sodium Intake

HF

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

Mr. Himm is consumes excessive sodium. Limiting Na will ameliorate his symptoms.

Fluid Intake

HF

Fluid intake should be <2 Liters/day for HF patients with edema and dyspnea, Fluid restriction improves symptomsand 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

Mr. Himm suffers from dyspnea with activity and peripheral edema. Fluid restriction may benefit his condition.

B12HF

HF patients should take A multi-vitamin/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

Mr. Himm’s consume few vegetables (especially greens), so a multivitamin with B-vitamins may improve his condition.

EAL GuidelinesTopic EAL Guidelines Research Studies Rating/Relevance

to Mr. Himm

Nutrition Intervention, cont’d

DASH DietHTN

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

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.

Physical Activity

HTN

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

Mr. Himm is completely sedentary. Some PA would alleviate symptoms and lower his BP.

Weight Management

HTN

Patient should attain normal body weight (with BMI 18.5 - 24.9) which will reduce blood pressure.

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

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

Nutrition Intervention, cont’d

Fruits and Vegetables

HTN

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.

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 cross-sectional studies associated increased fruit and vegetable consumption with reduction in BP

Strong/Imperative, Grade I

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 guidelinesdo not apply at this time. His blood chemistry should be monitored and guidelinesImplemented 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.

Nutrition Care ProcessSubjectiveObjectiveAssessmentPlan

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 LearnedI 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-Heart-Failure_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.