Hypertension and Dyslipidemia
Creating a Nutrition Care Plan
We are going to use the data we collected in the Assess stage to form a nutrition care plan for HTN and dyslipidemia, considering each of these 9 key areas:
- Medication Adherence
- Dietary Patterns – Mediterranean Diet & DASH Diet
- Sodium Intake
- Saturated and Trans Fat Intake
- Fibre Intake
- Physical Activity
- Alcohol Intake
It is always important to check in with the client on medication adherence. You can ask a few simple questions:
- Are they taking their medication at the times prescribed?
- Do they always take their medication? If not, how frequently do they miss taking a dose? Why are they not taking it?
- Does the client notice any side effects when taking the medication (this may be a reason for other factors reported to you that may influence your plan of care – i.e. nausea, diarrhea, lack of appetite)?
Liaise with regarding medication education or changes, if needed (i.e. client reports a concern or symptom not yet documented).
- David recently switched to a new BP medication, Amlodipine (Norvasc) 10mg, which can cause constipation
- In this situation, you could liaise with PCP and consider a different blood pressure medication.
- You may also suggest a fibre supplement, like Metamucil, that can help relieve constipation.
Dietary Patterns – DASH Diet
Revisiting our dietary assessment, we can use the DASH dietary pattern to help us form our nutrition care plan.
For more information, read:
- “Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet,” a journal article from The New England Journal of Medicine.
- 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
As outlined in our assessment, David is not currently following the DASH diet as a method to help control his BP and lipids. Providing an overview of the importance of balanced meals and snacks using the DASH diet, you can target areas beneficial for controlling blood pressure and reducing cholesterol. It’s important that David has a basic understanding of healthy dietary habits and is able to understand it in a practical way.
We will use principles from the DASH diet to create a nutrition care plan for David. As you do this, keep in mind:
- Small goals lead to big achievements and motivate the client to pursue a goal.
- You do not have to change the entire diet in one appointment. This can be done in a step-wise manner, which is more likely to result in a successful outcome.
- Always ask the client for their opinion when making suggestions, it is important that they are a part of the process.
Some strategies from the DASH diet to consider as part of the plan to reduce sodium in clients with HTN include trying to:
- Choose vegetables and fruits more often (fresh or frozen without added salt).
- Limit processed, smoked, and cured foods.
- Avoid using salt at the table and reduce salt added during cooking.
- Avoid seasonings that contain the word ‘salt’ or ‘sodium’ (such as garlic salt, celery salt, or monosodium glutamate [MSG]).
- Flavour foods with herbs, spices, garlic, onion, lemon, or vinegars.
- Limit frozen convenience foods and fast food restaurant meals.
- Use the Nutrition Facts table to determine sodium amounts: try to avoid foods with 400 mg of sodium or more per serving.
- Read food labels to determine sodium amounts: look for ‘unsalted’ or ‘no added salt’ or ‘low in sodium’ or ‘salt-free’ items. Note that ‘sodium-reduced’ does not necessarily mean low sodium.
For more information, read Heart and Stroke Foundation of Canada’s “Managing your blood pressure” (PDF) resource.
As we noted during the assessment (i.e. medical History, BP readings, dietary recall), David has HTN and a high intake of sodium. To help David control his blood pressure, here are a few suggestions to reduce his sodium intake.
|Meal||David’s diet recall||Suggestions to reduce sodium|
|Breakfast||2 eggs, 2 pieces bacon*, 1 piece of white bread, 15 mL butter on bread, 1 coffee with 2 milk (2%)||
|Lunch||Turkey sandwich (2 slices of whole grain 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||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||
For David, the key message here is to reduce the amount of processed and packaged foods.
Saturated and Trans Fat Intake
To reduce saturated and trans fats, clients can be encouraged to try to:
- Choose unsaturated fats (olive oil, canola oil, soft non-hydrogenated margarine) more often than saturated fats (butter, cream) when cooking.
- Include fatty fish in a meal two to three times a week.
- Use skim or 1% milk rather than 2% or 3.25% milk or cream.
- Choose lean meat and poultry and trim off the fat and skin before cooking.
- Add nuts and seeds to salads and use nut butters as spreads.
- Limit fast food and processed food that is high in trans fats.
For more information, read Heart and Stroke Foundation of Canada’s “How to Manage Your Cholesterol” (PDF) resource.
As we noted during the assessment (i.e. History data, elevated lipid levels, dietary recall), David has dyslipidemia and high intake of saturated and trans fat. To help David control his dyslipidemia and reduce his LDL, here are a few suggestions to reduce his intake of saturated and trans fat.
|Meal||David’s diet recall||Suggestions to reduce saturated and trans fat|
|Breakfast||2 eggs, 2 pieces bacon*, 1 piece of white bread, 15 mL butter on bread*, 1 coffee with 2 milk (2%)||
|Lunch||Turkey sandwich (2 slices of whole grain 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||Not applicable|
|Dinner||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*||
To increase fibre intake, clients can be encouraged to try to:
- Choose whole vegetables and fruit instead of juice.
- Add extra vegetables and legumes to pasta, curries, casseroles, and soups.
- Leave the skin on vegetables and fruits.
- Add nuts and seeds to salads, yogurt, and cereal.
- Include oatmeal with ground flaxseed as a breakfast food.
- Choose grain products with “whole grain” as the first ingredient.
- Look for 2-4 grams fibre per serving on the Nutrition Facts table.
- Add psyllium husk (like Metamucil) to meals or snacks once per day.
Make sure to add in fibre slowly and increase fluid intake to prevent constipation.
As we noted during the assessment, David has inadequate fibre. Here are a few suggestions to help David increase his fibre intake.
|Meal||David’s diet recall||Suggestions to increase fibre intake|
|Breakfast||2 eggs, 2 pieces bacon, 1 piece of white bread*, 15 mL butter on bread, 1 coffee with 2 milk (2%)||
|Lunch||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||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||
Physical activity is an important component of health. It can help control blood pressure. Clients can be encouraged to try the following:
- To achieve health benefits, and improve functional abilities, adults should accumulate at least 150 minutes of moderate- to vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more.
- It is also beneficial to add muscle and bone strengthening activities using major muscle groups, at least 2 days per week.
- Those with poor mobility should perform physical activities to enhance balance and prevent falls.
For more information, read the Canadian Society for Exercise Physiology’s 24-Hour Movement Guidelines.
- David is not currently interested in engaging in more physical activity, as he would like to focus on dietary changes first.
- Main barrier is the lower back injury.
- Consider speaking to David and his PCP about involving a registered kinesiologist or physiotherapist regarding this barrier.
- No physical activity plan at this time.
Smoking affects blood pressure in 2 ways:
- Nicotine in cigarette smoke causes blood vessels to narrow, which increases blood pressure.
- Smoking makes blood pressure medications work less effectively.
Smoking also increases the risk for the buildup of plaque inside the arteries (atherosclerosis).
Counselling on smoking cessation is not within a dietitian’s scope, however, if a client is interested in quitting smoking you can provide the following tips:
- Set a Quit Date: Choose a date within the next seven days when you will quit smoking.
- Choose a method for quitting: Stop all at once OR cut down the number of cigarettes per day until you stop completely.
- Decide if you need medication or other assistance to quit: A dietitian can act as a motivator and check in on smoking cessation goals. However, clients should talk to their PCP or be referred to a smoking cessation program to determine if they would benefit from nicotine replacement therapy (NRT).
For more information on quitting smoking, read Heart and Stroke Foundation of Canada’s “Managing your blood pressure” (PDF) resource.
- David is not currently interested in quitting smoking. He wants to try and achieve his goals with nutrition-related changes.
- He is open to revisiting this in the future.
- No smoking cessation plan at this time.
Drinking alcohol can lead to:
- High blood pressure by interfering with the blood flow to and from the heart.
- Possible increase in triglycerides.
- Increase in the release of .
- Increase the flow of free fatty acids to the liver from fat tissue.
- Impede the body’s ability to break down fat.
Other evidence shows moderate alcohol consumption (1-2 drinks/day) from any source (beer, wine, or distilled liquor) is associated with a reduced risk of CVD.
However, alcohol can be addictive and high intakes are associated with physical abuse and accidental injury or death. There is a need for individual consideration.
Overall, to prevent hypertension and reduce BP in adults, individuals should limit alcohol consumption to ≤2 drinks per day.
For more information on recommendations surrounding alcoholic beverages, read the Canadian Centre on Substance Use and Addictions’ “Canada’s Low-Risk Alcohol Drinking Guidelines” brochure.
- David reported having 1-2 beers per night.
- This amount is within the guidelines for men (2 alcoholic beverages a day).
- Although David’s alcohol consumption is within moderation, he should consider the potential effect on his blood pressure and triglycerides (which are above the target range). Reducing his alcohol intake may or may not have beneficial outcomes on improving his biochemical data.
- After discussion with David, he does not want to give up alcohol entirely, but wants to try to reduce consumption.
- Plan could be to start by reducing alcohol consumption to 1 beer per night.
To help with stress using positive coping strategies clients can try:
- Physical activity
- Engaging in hobbies
- Breathing exercises
Avoid unhealthy stress busters such as:
If additional help is needed, consider a social worker, therapist, or psychologist.
- He tells you that he is coping well with his depression since seeing a therapist a couple years ago, and the medication he takes daily has helped.
- He plans to reduce his alcohol intake and is considering smoking cessation in the future.
- He also reports he talks to his wife and socializes with friends to relieve his stress, and doesn’t feel it is impacting his health and quality of life at this point.
- No plan for coping with stress is needed at this time.
Summary of Nutrition Care Plan Recommendations
Now that we have gone through all 9 of the key areas to investigate when creating a nutrition care plan, here is a summary of the recommendations.
|Area of Concern||Recommendations|
When working with clients with hypertension and dyslipidemia, you can refer to this summary and the Hypertension Canada’s Health Behaviour Management Guidelines.
David’s Nutrition Care Plan could be to:
- Incorporate the principles of the DASH diet
- Incorporate the recommended daily servings of whole grains, vegetables and fruits, low-fat dairy products, lean meats, nuts, seeds, legumes, fats, and oils.
- Reduce sodium by:
- Reducing intake of processed deli meats and replacing with baked lean meat.
- Reduce intake of processed foods like boxed mashed potatoes, chips, and canned soup.
- Use Nutrition Facts table to look for low sodium options.
- Replace saturated fat intake with unsaturated fats by:
- Using nut butter instead of butter.
- Having lean meats, like chicken, or fish instead of beef and bacon.
- Reducing potato chips as snack.
Increase fibre by:
Choosing whole grain bread instead of white bread.
Adding extra vegetables to soup.
Adding legumes or nuts and seeds to salads.
Choosing oatmeal instead of cheerios.
Start taking Metamucil once per day with lunch.
Reduce alcohol consumption to 1 beer per day
Evaluate the impact as current consumption patterns are within guidelines.
These recommendations do not have to be implemented all at once. In the next chapter we’ll discuss how to work with David to target his areas of interest and create SMART goals to implement the plan.
PART 2: PLAN COMPLETE. Pause to reflect on the strategies discussed and the potential factors we could include in David’s nutrition care plan.. When you’re ready, move on to Part 3: Implementation.
Primary Care Provider
Very Low-Density Lipoprotein
Common medical abbreviateion for Latin "hora somni", meaning "bedtime".