Hypertension and Dyslipidemia
Setting the Agenda
Before you begin your assessment or any interaction with a client, make sure to:
- Start out by greeting them and introducing yourself.
- Describe the role of a Registered Dietitian in terms of their health care.
- Invite them to the conversation to build rapport.
- Set the agenda for the appointment by asking about what brings them in and how you can help with the management of their blood pressure or cholesterol.
You are a Registered Dietitian (RD) at a Family Health Team. The client you are assessing is a 45 year old male named David Krulicki with hypertension, dyslipidemia, and depression. He is a plumber and lives with his wife Martha, who is responsible for grocery shopping and cooking. He has had financial stressors lately, though does not experience food insecurity.
David has agreed to see the RD because would like to implement lifestyle changes and avoid increasing his medications.
Gathering Data for an Assessment
When gathering data for your assessment make sure to collect information on the patient’s:
- Clinical Data (both Medical History and Social History)
- Anthropometric Data
- Biochemical Data
- Dietary Data
When gathering clinical data, consider:
- Diagnosis: Have they received a diagnosis from their doctor? Do they have one or more CVD-related diagnoses (hypertension, dyslipidemia)? Are they at risk of developing CVD? Duration of Diagnosis?
- Patient Medical History: Do they have other medical conditions (diabetes, chronic kidney disease, depression)?
- Family History: Did members of their family have CVD or other medical conditions?
- Management: Do they regularly see any other doctors or specialists?
- Medications: Are they on any drug therapies for or dyslipidemia? Keep medications in mind when assessing any possible drug nutrient interactions, for example, with many heart medications patients can’t drink grapefruit juice.
- Diagnosis: Hypertension (1 year since Diagnosis) and dyslipidemia (5 years since Diagnosis)
- Patient Medical History: Depression
- Losartan and hydrochlorothiazide (Hyzaar) 50 mg + 12.5 mg
- Amlodipine (Norvasc) 10mg , switched from being on Ramipril (Altace) 2 months ago
- Atorvastatin (Lipitor) 80 mg OD
- Fluoxetine (Prozac) 20 mg OD
- 1000 IU vitamin D OD
- His primary care provider (PCP) suggested an additional medication to manage his dyslipidemia
- He has come to see you because he does not want to take any additional medications and to try to control it with lifestyle changes
Cardiac Medication Classification
When gathering medications as part of the nutrition assessment, refer to this Cardiac Medications List (PDF). It summarizes the various classes of medications for HTN and dyslipidemia, and also details their side effects, nutrition interactions (for example, many HTN medications interact with grapefruit and natural liquorice), and the parts of the body they act on to help control blood pressure and lipids. Some common types of drug classes for HTN and dyslipidemia are listed below.
|Common medications for HTN||Common medications for Dyslipidemia|
A special note on diuretics: it’s important to differentiate between potassium sparing and non-potassium sparing as they greatly affect electrolytes.
It’s also important to gather information on the client’s social history, which will help you to tailor your nutrition plan later on.
When gathering social history, consider:
- Housing: What is their living situation? Do they live with others/have a support system?
- Income: Are they currently working? What is their main source of income? Do they have medical coverage?
- Substance use: Smoking? Alcohol use? Any other substances?
- Food security: Has anyone in their household gone without food in the past month because they couldn’t afford it?
- Physical activity: Do they exercise? Do they have an injury or live in an unsafe area making it difficult to get outside to exercise? Do they have access to exercise facilities or equipment?
- Housing: Lives with wife
- Income: Works as a plumber
- Substance use:
- Smoker. Has increased his smoking lately due to stress.
- Drinks 1-2 alcoholic beverages a night (beer, sometimes wine)
- Food security
- Does not indicate any concerns with the ability to purchase foods
- During this conversation, tells you his wife is responsible for grocery shopping and preparing meals
- Physical activity
- Has a lower back injury
- Used to walk with his wife for 15-30 minutes every night. Stopped recently.
- Expresses to you that he enjoys exercise but it causes pain
When gathering anthropometric data from the client, consider:
- Weight: Current body weight in kg. If the client is open to having this taken.
- Weight History: Do they have an interest in weight loss? Have they tried to lose weight before? Has their weight recently fluctuated? What was their highest and lowest adult body weight?
- Waist Circumference: Current waist circumference in cm. If the client is open to having this taken, it can be a valuable screening measurement.
- Height: Current height in cm.
- BMI: Body Mass Index. Always consider muscle mass when using this tool.
- Physical Assessment: What is their muscle tone? Any muscle wasting?
It’s important to ask if the client is comfortable having these measurements taken as this may trigger stress for some clients. If the client states that weight loss is a goal for them, it can be helpful to know:
- Why that goal is important for them
- If they have tried to lose weight before
- Any diets they have tried in the past
- How their weight has fluctuated over the years
- Weight = 80 kg
- Height = 175.5 cm
- BMI = 26 kg/m2
- Weight History = David reports his weight has been mostly stable over the past few years, however he has been gaining weight quickly over the past few months. The physician reports this as 15 pounds of weight gain in the past 6 months.
Blood pressure ranges
|Blood Pressure Category||SYSTOLIC mm Hg (upper number)||and/or||DIASTOLIC mm Hg (lower number)|
|Normal||Less than 120||and||Less than 80|
|Elevated||120 – 129||and||Less than 80|
|High Blood Pressure (Hypertension) STAGE 1||130 – 139||or||80 – 89|
|High Blood Pressure (Hypertension) STAGE 2||140 or higher||or||90 or higher|
|Hypertensive Crisis (consult your doctor immediately)||Higher than 180||and/or||Higher than 120|
For patients with high blood pressure, measurements should be taken and used in forming a treatment plan to reduce their BP to the targets in the table below. Note that target ranges differ for clients with HTN, DM, and by level of CV risk. Target ranges can also vary based on the physician’s assessment of client needs.
Blood pressure targets
|Patient Population||BP threshold for initiation of antihypertensive therapy||BP treatment target|
|SBP mmHg||DBP mmHg||SBP mmHg||DBP mmHg|
|Hypertension Canada High-Risk Patient*||≥ 130||N/A||< 120||N/A|
|Diabetes mellitus**||≥ 130||≥ 80||< 130||< 80|
|Moderate-to-High Risk (CV risk factors)**||≥ 140||≥ 90||< 140||< 90|
|Low Risk (no CV risk factors)**||≥ 160||≥ 100||< 140||< 90|
You also want to collect and assess any blood work they’ve done for lipids, including total cholesterol, HDL, LDL, and non-HDL cholesterol, and triglycerides.
For more information, read the 2016 Canadian Cardiovascular Society Dyslipidemia Guidelines (PDF)
|TC||Total cholesterol: amount of total cholesterol in blood||< 5.2 mmol/L||≤ 4.0 mmol/L|
|HDL Chol||High density lipoprotein: “good” cholesterol absorbs cholesterol and carries it back to liver||≥ 1.0 mmol/L
|≥ 1.0 mmol/L|
|LDL Chol||Low density lipoprotein: “bad” cholesterol leading to plaque build up resulting in heart disease||< 3.5 mmol/L||≤ 2.0 mmol/L|
|Non-HDL Chol||Total cholesterol – HDL = Non-HDL Chol
Includes VLDL, IDL, Lp(a), LDL, etc.
|< 4.0 mmol/L||≤ 2.6 mmol/L|
|TG||Triglycerides: fat found in blood used for energy; excess fat storage||≤ 1.7 mmol/L
|≤ 1.7 mmol/L|
Here are the BP measurements for David. Use the BP target values provided above to determine if David falls within normal range or is above target. This information will be used when planning the nutrition care plan in the next section.
|Measurement Date||BP Result|
|Lab Test||Lab Result||Target Range|
|TC||6.2 mmol/L||≤ 4.0 mmol/L|
|LDL||4.2 mmol/L||≤ 2.0 mmol/L|
|HDL||0.8 mmol/L||≥ 1.0 mmol/L|
|TG||4.0 mmol/L||≤ 1.7 mmol/L|
In David’s case, his A1C is normal. If it was not, you should talk to his .
When gathering dietary data, you should consider the client’s:
- Diet History: 24-hour recall or 3-day food record. Have they tried any diets in the past? Are they following the Dietary Approach to Stop Hypertension (DASH) diet?
- Eating behaviours/patterns: How many meals per day and how many hours between their meals and snacks? Eating at home or eating out?
- Cardiac dietary areas of concern: Intake of fibre, saturated fat, unsaturated fat, sodium and other electrolytes
- Food skills and access: Do they have access to a kitchen? Do they have access to a grocery store? Do they get groceries and/or cook at home, or does someone else do this for them? Previous nutrition education? What do they know about managing their blood pressure or cholesterol with diet choice
The Mediterranean Eating Pattern
The American Heart Association guidelines on lifestyle management to reduce CVD risk recommends following a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. Individuals can achieve this well-balanced dietary pattern by following the Mediterranean diet, Canada’s Food Guide (CFG), or the diet and adapt it with help from an RD to ensure it suits their energy and protein requirements, personal and cultural food preferences, and meets any nutrition therapy needs for other medical conditions, like diabetes. Following a dietary pattern like this can help clients with HTN and dyslipidemia reduce their CVD risk.
The Mediterranean Diet is:
- Low in saturated fat
- Very low in trans fat
- Rich in unsaturated fat
- Rich in starch and fibre
- Rich in nutrients and phytochemicals that support good health
DASH Eating Pattern
The Dietary Approach to Stop Hypertension (DASH) diet has been shown to help manage and even prevent high blood pressure. Similar to the Mediterranean diet and , it emphasizes whole grains, vegetables and fruits, low-fat dairy products, lean meats, and is low in saturated and trans fats. It also works on a serving size system, so keep in mind that clients using this will have to be educated on serving sizes.
For more details, read the Vermont Department of Health’s DASH Eating Plan resource (PDF).
|Food Group||Daily Servings||Serving Sizes (1 serving is equivalent to)|
1 slice of bread
1 ounce of dry cereal
½ cup of cooked rice, pasta, cereal
1 cup raw leafy vegetables
½ cup cut up raw or cooked vegetables
1 medium piece of fruit
¼ cup dried fruit
½ cup fresh, frozen or canned fruit
|Fat-free or low-fat dairy products||2-3||
1 cup yogurt
1 ½ ounce cheese
|Lean meats, poultry, fish||2 or fewer||
3-ounce cooked meats, poultry of fish
|Nuts, seeds, and legumes||4-5 per week||
1 tbsp of peanut butter or seeds
½ cup cooked legumes
|Fats and oils||2-3||
1 tsp margarine (non-hydrogenated)
1 tbsp mayonnaise
1 tsp vegetable oil
|Sweets||5 per week||
½ ounce jelly beans
- To decrease BP, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).
- Although sodium recommendations are more liberal, compared to healthy people, the majority of people with hypertension consume too much sodium, > 3000 mg/day.
For more information, read Hypertension Canada’s 2020 Comprehensive Guidelines for Adults and Children (PDF).
Fat Intake Recommendations
Reviewing fat intake and the different types of fat in the diet is key when working with a client who has high cholesterol or dyslipidemia, as intake of food with saturated and trans fat has a greater impact on blood cholesterol levels than intake of dietary cholesterol. Here are the recommendations surrounding intake of the different types of fat, like trans fat, saturated fat, and unsaturated fat, particularly omega 3, 6, and 9.
|Type of Fat||Recommendation||Foods That Contain The Fat|
|Unsaturated Fats||Include most often
(2-3 tbsps a day)
|Omega 3||Include more often
(2-3 servings of fish a week)
|Omega 6 & 9||Include in small amounts||
(<5-10% of total daily fat intake)
Fibre Intake Recommendations
Reviewing fibre intake and the different types of fibre in the diet is key when working with a client who has high cholesterol or dyslipidemia, as intake of soluble fibre can reduce cholesterol by inhibiting cholesterol and bile absorption in the small intestine. Women need at least 25 grams of fibre per day, and men need at least 38 grams of fibre per day.
|Fibre Type||Benefits||Food Sources|
|Soluble Fibre||Can reduce cholesterol by inhibiting cholesterol and bile absorption in the small intestine.||
|Insoluble Fibre||Provides fecal bulk to help promote regular bowel movements. Can prevent colon cancer and diverticular disease and increases satiety.||
- His wife does the grocery shopping and cooking.
- Eats out twice a week at fast food or dine-in restaurants. Mostly for lunch.
- He reports that his meals are consistent and the diet recall represents his typical patterns.
- He reports having no prior nutrition education.
Diet History (24-hour recall):
|Meal||David’s diet recall|
|Breakfast 9 am||2 eggs, 2 pieces bacon, 1 piece of white bread, 15 mL butter on bread, 1 coffee with 2 milk (2%)|
|Lunch 1-2 pm||Turkey sandwich (2 slices of white bread, 2 slices of deli turkey, tbsp of mayo, tbsp of mustard, 2 slices of cheddar cheese, lettuce, and tomato) with 1 cup of soup (canned tomato or mushroom), 500 mL of water|
|Dinner 5:30-6:30 pm||6 ounces of meat (beef), 1 cup mashed potatoes, 1 cup of salad, 500 mL of water|
|HS snack||1 bowl of cereal (cheerios) with 1 cup of 2% milk and a small bag of chips with 1-2 beers|
PES Statements for Dietary Data
Common PES Statement Terminology
As you interpret the dietary data from the assessment, you can form Problem, Etiology, Symptoms (PES) statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this resource from the Academy of Nutrition and Dietetics. Here are some common nutrition problems that patients with HTN and dyslipidemia may experience:
- Excessive saturated fat intake
- Less than optimal intake of types of fats (specify)
- Inappropriate intake of fats
- Inadequate vegetable and fruit consumption
- Inadequate fibre intake
- Excessive sodium intake
- Imbalance of nutrients
- Physical inactivity
- Altered nutrition-related laboratory values (specify)
- Food- and nutrition-related knowledge deficit
- Impaired ability to prepare food/meals
- Not ready for diet/lifestyle change
Use the dietary assessment data you have collected from David so far to form a PES statement for his intake of sodium, fat, fibre, and DASH diet recommendations.
You can use the questions below to guide you:
- Is David meeting the DASH Diet recommended amount of whole grains, vegetables and fruit, dairy products, and lean meats and poultry in his diet recall?
- Is he exceeding the daily recommended amount of sodium?
- Is he consuming excess saturated fat and is his intake of unsaturated fats sources adequate?
- Is his fibre intake adequate?
- Are there any potential drug nutrient interactions?
These are some examples of PES statements that you may have formed for David based on his intake.
For example, if we count his fruit and vegetable intake, it looks like he is only getting about 2-3 servings. Therefore, he has an imbalance of nutrients related to food and nutrition knowledge deficit of healthy dietary patterns as evidenced by not meeting DASH diet recommendations for vegetables and fruit. He also has excessive sodium intake, excessive intake of saturated and trans fats, and inadequate intake of fibre.
These PES statements will be used later on in the section when forming the nutrition care plan:
- Imbalance of nutrients related to food and nutrition knowledge deficit of healthy dietary patterns as evidenced by not meeting DASH diet recommendations for whole grains, vegetables and fruit, dairy products, lean meats, poultry, fish, fats, and oils.
- Excessive sodium intake related to a knowledge deficit of sodium sources and importance of sodium reduction for blood pressure control as evidenced by high intake of processed foods such as bacon, deli meat, canned soup, etc.
- Excessive intake of saturated and trans fat related to a lack of food preparation knowledge and skills as evidenced by high intake of processed meat, red meat, and chips.
- Inadequate intake of fibre related to a knowledge deficit of food sources of fibre as evidenced by low intake of vegetables and whole grains.
Simulation Activity: David
PART 1: ASSESS COMPLETE. Pause to reflect on the assessment strategies discussed. When you’re ready, move on to Part 2: Plan.
hypertension; high blood pressure
Common medical abbreviation of "bis in die", Latin for "twice per day".
Primary Care Provider
Dietary Approach to Stop Hypertension
Canada's Food Guide