MNT in a Patient with Diabetes Status Post Myocardial Infarction MEGAN SOLLOWAY University of Maryland Dietetic Intern March 31, 2015
ST-elevated Myocardial Infarction (STEMI) ▪ Blood clot blocks blood flow ▪ Death of heart tissue downstream
▪ ST-elevation in echocardiogram
ST-elevated Myocardial Infarction (STEMI) ▪ Treatment – Restore blood flow ▪ Surgical removal of clot ▪ Stent placement ▪ Angioplasty
▪ Increase risk – hx of diabetes, hyperlipidemia, hypertension, obesity
Dietary Interventions ▪ Comfort care immediately post-STEMI ▪ Small frequent meals
▪ Transition to Therapeutic Lifestyle Changes (TLC) once stable ▪ Nutrition counseling strategies ▪ Goal Setting ▪ Self-monitoring ▪ Problem solving
▪ Follow-up with an outpatient clinic for cardiac rehab
Non-Traditional Treatment ▪ Nutrition supplements ▪ Magnesium ▪ Carnitine ▪ Co-enzyme Q10
▪ Amino Acids ▪ Arginine ▪ Taurine
▪ Herbal Medications ▪ Hawthorn ▪ Berberine ▪ Taurine (cardio-preventative)
Nutrition Assessment MEET RK!
General Information ▪ 56 year-old white female
▪ Admitted September 15th, 2014 ▪ 2 days in CCU and 2 days in PCU ▪ Discharged September 18th, 2014
▪ Symptoms ▪ ▪ ▪ ▪ ▪ ▪
Sub-sternal chest tightness Bilateral shoulder pain Tingling in fingers Diaphoresis N/V Headache
Medical Data ▪ Medical hx ▪ ▪ ▪ ▪ ▪ ▪ ▪
Obstructive Sleep Apnea Hypertension Hyperlipidemia (w/ statin intolerance) Hypothyroidism Fibromyalgia Chronic Fatigue Syndrome Rheumatoid Arthritis
▪ Recent Type 2 Diabetes dx ▪ No food allergies or major surgical history
Anthropometrics and Nutrition-Focused Physical Findings ▪ Notable labs
Current height
5’3”
Current weight
183 lb (83 kg)
▪ No change in appetite PTA
Ideal Body Weight
115 lb (52.3 kg)
▪ Intentional 34 lb wt loss over 6 years (“First Diet”)
% IBW
159%
▪ Hgb A1C – 10.4% ▪ Blood Glucose – 246-340 mg/dl
▪ Stable over past 6 months
▪ Modified diet to improve blood glucose control w/Type 2 diabetes dx ▪ No RD instruction (personal internet research)
Adjusted body weight 132 lb (60kg)
% UBW
102%
BMI
30.5
Food and Nutrition Related History ▪ Outpatient Medications – Lantus, Glimepride, Benicar, Janjumet, K-Dur
▪ Inpatient Medications – Novolog, Lantus, Benicar, Crestor, Plavix, Lovenox, Lopressor, ▪ Married w/no children ▪ No smoking or EtOH abuse history ▪ Retired school teacher ▪ Receives social security and supplemental disability benefits
▪ Food Prep ▪ RK does the food shopping and cooking ▪ Does not use a salt shaker
▪ Limited Physical Activity r/t Chronic Fatigue
Nutrition Diagnosis “Food and nutrition related knowledge deficit related to lack of prior nutrition related education (cardiac/diabetes) as evidence by recent STEMI�
Intervention NUTRITION EDUCATION!
Estimated Nutrient Needs ▪ Comfort care for first few days ▪ Small, frequent meals
▪ TLC Diet (NCM) once stable ▪ <7% of energy from saturated fat and no trans fats ▪ <200mg cholesterol/day ▪ 25-35% of calories from fat ▪ 50-60% of calories from carbohydrate and 15% from protein ▪ 25-30g fiber/day, with 50% coming from soluble fiber ▪ Moderate exercise to expend 200 calories per day
Source
Kcal
Facility 1200 kcal Standards (BEEx1.2, 500 kcal for 1 lb weight loss/week) Evidence Analysis Library (EAL) Online (NCM)
Protein
Fluid
60-72 g (1.0-1.2 g/kg Adjusted Body Weight)
1500-2400 ml/d (25-40 ml/kg Adjusted Body Weight/d) 1391 No No kcal/d conclusive conclusive (Mifflin St. recommend recommen ations dations Jeor)2 1395 kcal 52 g protein 1395 ml/kcal (15% of calories)1 (1ml/kcal)1
Nutrition Education ▪ MD Consult for Cardiac & Diabetic Diet
▪ 3 handouts provided ▪ Carbohydrate Counting for People with Diabetes ▪ Heart Healthy Nutrition Therapy ▪ Physical Activity with Chronic Fatigue Syndrome
▪ No prior diet education ▪ Discussed food/mood diary for emotional eating ▪ MD interruption
Nutrition Goals ▪ Weight loss (1 lb/week)
▪ Improved HgbA1c (<6%) ▪ Improved lipid panel (total cholesterol < 200 mg/dl, LDL < 70 mg/dl, HDL > 60 mg/dl, triglycerides < 150 mg/dl).
Monitoring and Evaluation WEIGHT, HGBA1C, LIPID PANEL
Implications of Findings to Dietetics ▪ RD’s play a large role in dietary counseling of patients with CVD and diabetes ▪ Goal setting ▪ Problem solving ▪ Self-monitoring
▪ Small, meaningful changes ▪ Meet the patient where they are!
▪ Watch for potential herbal-drug interactions