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

▪ Hgb A1C – 10.4%

▪ Blood Glucose – 246-340 mg/dl

▪ No change in appetite PTA

▪ Intentional 34 lb wt loss over 6 years (“First Diet”)

▪ Stable over past 6 months

▪ Modified diet to improve blood glucose control w/Type 2 diabetes dx

▪ No RD instruction (personal internet research)

Current height 5’3”

Current weight 183 lb (83 kg)

Ideal Body Weight 115 lb (52.3 kg)

% IBW 159%

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 Protein Fluid

Facility

Standards

1200 kcal

(BEEx1.2, -

500 kcal

for 1 lb

weight

loss/week)

60-72 g

(1.0-1.2

g/kg

Adjusted

Body

Weight)

1500-2400

ml/d

(25-40

ml/kg

Adjusted

Body

Weight/d)

Evidence

Analysis

Library

(EAL)

1391

kcal/d

(Mifflin St.

Jeor)2

No

conclusive

recommend

ations

No

conclusive

recommen

dations

Online

(NCM)

1395 kcal 52 g protein

(15% of

calories)1

1395

ml/kcal

(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