HNSC4240 Clinical Nutrition I

Case study 1 Spring 2022

PLEASE READ THE INSTRUCTION CAREFULLY. Read the following fictitious medical
record from a patient who has coronary artery disease. Answer the questions below. Noted
that some questions will require that you search for scientific evidence from reliable sources.
Please include AT LEAST TWO references in standard scientific citation format. The
assignment must be typed. The assignment is due on March 9. Late assignment will be
subjected to 1 point deduction each day.

Client Name: Jose Garcia

DOB: 12/1
Age: 61
Sex: male
Education: AA degree
Occupation: IT work specialist
Household members: Married, Spouse name: Alice Garcia, 59 yo
Ethnicity: Mexican American

History: 61-yo male who noted the sudden onset of severe precordial pain on the way home from
work. The pain is described as pressure-like pain radiating to the jaw and left arm. The patient has
noted an episode of emesis and nausea. He denies palpitations or syncope. He denies prior history
of pain. He admits to smoking cigarettes (1 pack/day for 40 years). He denies hypertension,
diabetes, or high cholesterol. He denies SOB.
Medical History: Not significant before this admission.
Tobacco use: 40-year history, 1 pack/day
Alcohol use: 1 glass of wine per day
Family history: What? Coronary heart disease Who? Father- Myocardial infarction age 50

Allergies: Allergic to shellfish

Vitals: Blood pressure 140/99, pulse 94, temperature 36.9C
Abdomen: bowel sound present, non-distended, non-tender
Height: 5'8"
Weight: 215 lbs

Lab
Values Reference Units
Sodium 141 136-145 mEq/L
Potassium 4.1 3.5-5.5 mEq/L
Glucose 103 70-110 mg/dL
Calcium 9.4 9-11 mg/dL
Albumin 4.2 3.5-5 g/dL
Prealbumin 30 16-35 mg/dL

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 LDH (lactate dehydrogenase) 405 208-378 U/L
Alk phos (alkaline 150 30-120 U/L
phosphatase)
LDL 160 <130 mg/dL
HDL-C 50 30 mg/dL

Nutrition Consult: Patient admitted to cardiology ischemia pathway with known or suspected
CAD. Please facilitate initial and outpatient education.

Nutrition history:
General: Appetite was good. Has been trying to change some things in his diet. Wife indicates that
she would like to know more about heart healthy cooking and supplement use.

24-hr recall
Breakfast: 1 c coffee (with 1 tbsp half and half, 2 tsp table sugar)
Midmorning snack: Egg and cheese on English muffin from work cafeteria (1 egg, 1oz cheese, 1
English muffin); 8 oz. orange juice, 2 c coffee with milk and sugar (with 1 tbsp half and half, 2 tsp
table sugar)
Lunch: Leftovers from home; if eats in cafeteria: soup, salad, or sandwich. Had tomato soup (1
cup) and grilled cheese sandwich yesterday.
Dinner: Rice – 1 c; black beans- 1 c; roast pork with tomato and peppers – approx. 6 oz;
cornbread – 2 squares, each 2" wide
HS snack: None yesterday but typically has cookies or ice cream

Medications: Atenolol 75 mg/d; Nitroglycerin 1/150 (0.4 mg) 1 TAB SL q 5 min x 3 prn chest
pain; hold if: SBP < 100 mm Hg
Eptifibatide 180 µg/kg IV bolus x 2, 10 min apart, followed by IV infusion of 2.0 µg/kg/min,
reduce to 1.0 µg/kg/min if CrCl < 50 mL/min
Enoxaparin 1 mg/kg SC q 12 h (if CrCl < 30 mL/min, give 1 mg/kg every 24 h)

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Sayra Feng Wu
Prof. Xinyin Jiang
HNSC 4240
03/08/2022
Case Study 1
Questions:
1. Please calculate and classify Mr. Garcia's BMI. Use the very quick method estimate his calorie
need. Identify the cardiovascular risk factors that Mr. Garcia has that determine his LDL goal.
Specify his LDL goal.
 BMI = 215lbs * 703 / (68in^2) = 151,145 / 4624 = 32.7  Obesity class I
 The very quick method: 20 * (215/2.2) = 20 * 97.7 = 1,954 calories Mr. Garcia needed for
his energy requirement.
 Mr. Garcia's cardiovascular risk factors that determine his LDL goal are his age of 61
years, family history of his father with myocardial infarction at age 50, and blood
pressure of 140/99 mmHg. His LDL value is 160 mg/dL, but he needs to be less than 130
mg/dL since he has three risk factors.

2. Mr. Garcia had a myocardial infarction. In the cardiac catherization lab he was "found to have a
totally occluded distal right coronary artery and a 70% occlusion in the left circumflex coronary
artery. The left anterior descending was patent. Angioplasty of the distal right coronary artery
resulted in a patent infarct-related artery with near-normal flow. A stent was left in place to
stabilize the patient and limit infarct size. Left ventricular ejection fraction was normal at 42%,
and a posterobasilar scar was present with hypokinesis." Explain what happened to his heart
muscle and vascular system. Explain angioplasty and stent placement.
The pathological changes associated with myocardial infarction (MI) are:
 "Inadequate perfusion of the heart muscle can contribute to an irreversible
myocardial hibernation and decrease of contractile function." (Awada, Hwang, &
Wang, 2015).
 Metalloproteinases (MMPs) involve "angiogenesis, wound healing, extracellular
matrix homeostasis, proliferation, and apoptosis. After MI, a significant increase in
MMP activity leads to an imbalance in the MMP/TIMP ratio favoring the
degradation of the myocardial ECM over deposition." (Awada, Hwang, & Wang,
2015).
According to the explanation of the NIH website, angioplasty is a surgery to "open narrowed
or blocked blood vessels that supply blood to the heart," and stent placement is a small metal tube
used in the angioplasty to expand the coronary arteries. (MedlinePlus).

3. Use food composition table or any diet analysis software/ online program, estimate Mr. Garcia's
protein, carbohydrate, fiber, sodium, potassium, total fat, saturated fat, monounsaturated fat,
polyunsaturated fat, cholesterol and calories from his 24-hr recall. Please use the table below as a
template or provide a printout of the nutrition analysis report if you completed this part using diet
analysis software (you may expand the columns and rows).

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 Food items Prote Carbo Fiber Sodium Total Saturat Mono Poly Choleste Energy
in hydrat (g) (mg) fat ed fat (g) (g) rol (Cal)
(g) e (g) (g) (g) (mg)
Coffee 0.9 3.3 3.3 14.2 0.1 0 0.1 0 0 7.1
Sugars 0 16.7 0 0.2 0 0 0 0 0 64.5
Half and 0.9 1.3 0 18.3 3.5 2.1 1 0.2 10.5 39.3
Half
English 5.1 25.2 2 242.3 1 0.4 0.2 0.3 0 129.4
muffin
Eggs 6.3 0.6 0 62 5.3 1.6 2 0.7 186.5 77.5
Cheese 6.5 1 0 185.1 9.4 5.3 2.3 0.4 28.1 114.2
Orange 1.7 25.8 0.5 2.5 0.5 0.1 0.1 0.1 0 111.6
juice
Tomato 3.2 13 2.3 592.6 8.8 4.3 3.5 0.5 22.1 133.8
soup
Grilled 12.6 29.7 1.5 1085.1 24.1 10.3 5.4 5.3 42 380.5
cheese
sandwich
Black beans 14.2 44.8 18.1 662.2 1.1 0.2 0.2 0.8 0 240.8
Roast pork 37.8 0 0 87.1 7.4 2.4 2.8 1.1 101.8 227.8
Tomato 0.6 2.6 0.8 3.4 0.1 0 0 0.1 0 12.2
Pepper 0.4 2.2 0.8 1.5 0.1 0 0 0.1 0 9.6
Cornbread 7.6 46.6 1.7 492 12 5.1 4.4 1.3 70.9 327.5
Total 97.8 212.8 31 3448.5 73.4 31.8 22 10.9 461.9 1875.8

4. Compare Mr. Garcia 24-hr dietary intake (the "totals" from question 3) with the TLC dietary
guidelines and/or other dietary guidelines. Complete the following table (noted that column 3
needs to have the same units as column 2 in order to be comparable). Point out two nutrients that
are NOT consistent with the guidelines that are of major concern to you and explain the reasoning.

Nutrient Recommended amount/ percentage Garcia's intake per 24-hr

recall
Protein ~15% of total calories = 293.1 kcal = 97.8 grams
73.3 grams
Carbohydrate 50-60% of total calories = 977-1,172.4 212.8 grams
kcal = 244.3-293.1 grams
Fiber 20-30 grams per day 31 grams
Sodium Less than 1500 mg per day 3448.5 mg
Total fat 25-35% of total calories = 488.5-683.9 73.4 grams
kcal = 54.3-76 grams
Saturated fat Less than 7% of total calories = 136.78 31.8 grams
kcal = 15.2 grams
Mono-unsaturated fat Less than or equal to 20% of total 22 grams

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 calories = 390.8 kcal = 43.4 grams
Poly-unsaturated fat Less than or equal to 10% of total 10.9 grams
calories = 195.4 kcal = 21.7 grams
Cholesterol N/A 461.9 mg
Energy 1,954 kcal 1876 kcal

Two nutrients not consistent with the guidelines:

The total fat and dietary sodium intake of Mr. Garcia are not consistent with the TLC dietary
guidelines because both outstanding intakes can increase the risk of CHD and obesity.

5. His wife asks you to show her how to modify recipes to make them heart healthy. Please make
at least 3 changes on one of the meals (breakfast, lunch, or dinner) from the 24-hr dietary recall.
Use the table below as a template and only include the items that need to be modified in the table.
From his lunch and his fluid intake, I would recommend doing these modifications:
Food items Modification/Alternative(s) Rationale
Half and half 2% milk Lower total fat in 2% milk
Grilled cheese sandwich Avocado with whole wheat Lower sodium and calories in
toast and salmon or chicken avocado toast, but also to
breast meet up his protein need for a
day
Tomato soup Low sodium varied vegetable Vary the vegetable intake
soup

6. Assess Mr. Garcia's blood work and explain how the biomarkers indicate his CVD risk.
Mr. Garcia's blood test results have shown high LDL value and near-high blood glucose level,
which indicate the high risk of having CVD. Also, the high LDH and Alk Phos values may
indicate possible organ tissue damage, such as heart and liver damage.

7. Mrs. Garcia said that she did some search online and found some nutritionists who advised
patients to get rid of starchy food in diet to lose weight and control CVD. Mr. Garcia said that he's
never going to give up his carbs. Identify a peer-reviewed article on the relationship between
carbohydrate intake or a ketogenic diet and CVD outcomes. Briefly describe the study design,
methods, results and conclusions. What would be your advice to Mr. and Mrs. Garcia?
The article was published in 2020 by multiple authors, named Relationship between the
carbohydrate and dietary fiber intake and the risk of cardiovascular disease mortality in
Japanese: 24-year follow-up of NIPPON DATA80.
 Study design: a prospective, cohort study
 Methods: The study had followed 3916 men and 5009 women in a total of 8925
participants for 24 years. The participants are the age of 30 to 79 without cardiovascular
disease, and they submitted the National Nutrition Survey in Japan.
 Results: There were 823 deaths related to cardiovascular disease during the study, yet no
evidence has shown the association between the amount intake of carbohydrates and

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 CVD mortality.
 Conclusions: Overall, "intake of carbohydrate, available carbohydrate, and starch were
not associated with the risk of CVD mortality in men or women." (Miyazawa et al.,
2020). In addition, a higher intake of dietary fiber could lower CVD risk more efficiently.
My recommendation for Mr. and Mrs. Garcia is to keep low carbohydrates intake in Mr. Garcia,
but limit the added sugar and refined carbohydrates intake due to Mr. Garcia’s BMI is classified as
obesity class I. Instead, increase the dietary fiber intake and consume whole wheat products
because the study have shown that dietary fiber can lower the risk of having CVD. Hence, it can
reduce multiple risk factors he has.

LITERATURE CITED

Alkaline Phosphatase: MedlinePlus Medical Test. (2020, July 30). Retrieved from
https://medlineplus.gov/lab-tests/alkaline-phosphatase/#:~:text=An alkaline phosphatase (ALP)
test,may leak into the bloodstream.  

Angioplasty and stent placement - heart: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from
https://medlineplus.gov/ency/article/007473.htm#:~:text=Angioplasty is a procedure to,during or
immediately after angioplasty.

Awada, Hwang, M. P., & Wang, Y. (2015). Towards comprehensive cardiac repair and regeneration after
myocardial infarction: Aspects to consider and proteins to deliver. Biomaterials, 82, 94–112.
https://doi.org/10.1016/j.biomaterials.2015.12.025

Lactate Dehydrogenase (LDH) Test: MedlinePlus Medical Test. (2020, December 17). Retrieved from
https://medlineplus.gov/lab-tests/lactate-dehydrogenase-ldh-test/#:~:text=What is a lactate
dehydrogenase,in making your body's energy.

Miyazawa, I., Miura, K., Miyagawa, N., Kondo, K., Kadota, A., Okuda, N., Fujiyoshi, A., Chihara, I.,
Nakamura, Y., Hozawa, A., Nakamura, Y., Kita, Y., Yoshita, K., Okamura, T., Okayama, A., &
Ueshima, H. (2020). Relationship between carbohydrate and dietary fibre intake and the risk of
cardiovascular disease mortality in Japanese: 24-year follow-up of NIPPON DATA80. European
Journal of Clinical Nutrition, 74(1), 67–76. https://doi.org/10.1038/s41430-019-0424-y 

Neumann, Kósa, I., Dickfeld, T., Blasini, R., Gawaz, M., Hausleiter, J., Schwaiger, M., & Schömig, A.
(1997). Recovery of Myocardial Perfusion in Acute Myocardial Infarction After Successful
Balloon Angioplasty and Stent Placement in the Infarct-Related Coronary Artery. Journal of the
American College of Cardiology, 30(5), 1270–1276. https://doi.org/10.1016/S0735-
1097(97)00300-8