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
• Smoking
• Alcohol Intake
• Stress

Medication Adherence

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 PCP regarding medication education or changes, if needed (i.e. client reports a concern or symptom not yet documented).

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).

Sodium intake

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.

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.

Fibre

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.

Physical Activity

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.

Smoking

Smoking affects blood pressure in 2 ways:

1. Nicotine in cigarette smoke causes blood vessels to narrow, which increases blood pressure.
2. 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:

1. Set a Quit Date: Choose a date within the next seven days when you will quit smoking.
2. Choose a method for quitting: Stop all at once OR cut down the number of cigarettes per day until you stop completely.
3. 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).

Alcohol Intake

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 VLDL.
• 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.

Stress

To help with stress using positive coping strategies clients can try:

• Physical activity
• Socializing
• Laughter
• Engaging in hobbies
• Breathing exercises

Avoid unhealthy stress busters such as:

• Smoking
• Alcohol

If additional help is needed, consider a social worker, therapist, or psychologist.

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.

When working with clients with hypertension and dyslipidemia,  you can refer to this summary and the Hypertension Canada’s  Health Behaviour Management Guidelines.