Learning Outcomes
By the end of this section, you should be able to:
- 11.2.1 Prioritize hypotheses of nutritional habits that optimize cardiovascular wellness.
- 11.2.2 Generate solutions to optimize cardiovascular wellness through nutritional habits.
Planning Nutritional Goals
Several body metrics can help the nurse evaluate the potential for cardiovascular disease development or to determine level of cardiovascular disease present. These metrics include food intake, body mass index (BMI), waist-to-hip ratio, blood pressure, and cholesterol. The primary goal is to utilize the best nutritional practices to prevent cardiovascular disease. If disease is present, nutrition is used to help control the condition and prevent worsening and exacerbation periods.
Preventative Care Nutritional Planning
Preventative nutritional planning should focus on a client who does not yet have cardiovascular disease. Prevention is always the highest priority for clients with a known risk of cardiovascular disease but should also be routine education for all clients, as it affects a large portion of the population. Planning for disease prevention includes monitoring weight and BMI, cholesterol levels, waist circumference, and intake of sodium, potassium, magnesium, calcium, fluid, and fiber.
When educating the client on proper nutritional practices to reduce the risks of developing cardiovascular disease, the client must first understand how to properly manage cholesterol levels and the differences in the types of fats they ingest in relation to these levels. Three main types of fat are most often discussed in relation to cardiovascular disease and its prevention—unsaturated fats, saturated fats, and trans fats, which are a form of unsaturated fat. Saturated fats and trans fats are in semi-solid form at room temperature. Like all fats, they are made up of carbon, oxygen, and hydrogen, but they have more hydrogen molecules than other forms of fat (Moll, 2022). Saturated fats and trans fats are more likely to form deposits inside arteries and harden as plaques, making them forms of fat that the client should limit to less than 6% of their daily intake (Moll, 2022). High intake of saturated and trans fats can increase the client’s levels of low-density lipid (LDL) cholesterol levels (Moll, 2022). This is typically referred to as “bad” cholesterol in the body, as it is the type most likely to deposit and stick to artery walls. While not all LDL is harmful and plaque forming, it still puts the client at higher risk when they consistently have higher LDL levels. High-density lipid (HDL) cholesterol is referred to as “good” cholesterol because of its low risk of plaque depositing. Unsaturated fats should make up the majority of the daily recommended 20–35% of daily fat intake (Moll, 2022).
Maintaining adequate fiber intake will help to prevent cardiovascular disease. Fiber has been shown to lower LDL cholesterol levels, lower blood pressure, and create satiety (a feeling of fullness) to help in weight loss (Harvard Health Publishing, 2020). When increasing fiber intake, it important to also increase fluid intake, particularly water intake, to prevent constipation. Adequate fluid intake (particularly water) of at least 6–8 cups per day for women and 8–12 cups per day for men is needed for many body processes, including proper blood vessel function, blood circulation, effective cardiac pumping, and sodium level maintenance, which can help prevent heart disease risk if maintained at 142 milliequivalents per liter (mEq/L) and below (Dmitrieva, Liu, Wu, & Boehm, 2022; National Institutes of Health, 2022).
Another important piece of education for the client is the proper regulation of their daily sodium intake. Too much daily intake can increase the risk of hypertension, which can lead to heart failure. Americans consume an average of 3400 mg/day of sodium, which is well above the recommended limit of 2300 mg/day for those without heart disease (American Heart Association, 2023). This maximum is still not optimal as the AHA recommends that clients without heart disease move toward a limit of 1500 mg/day and those with heart disease to 1000 mg/day. While this is the current recommendation, there is some debate from new findings by the American College of Cardiology (2023) that individuals with heart disease do not benefit from limiting their sodium any more than those without heart disease.
The nurse should have a nutrition education discussion with the client that includes maintaining a proper diet for healthy BMI, waist circumference, calcium, magnesium, and potassium levels. The nurse can discuss both the use of the MyPlate and DASH diets to accomplish this. The nurse should keep in mind, however, that a fine balance must be maintained between potassium, sodium, magnesium, and calcium for proper conduction and mechanic pumping of the heart to take place. Most clients can maintain these three electrolytes through balanced nutrition, but if they are deficient in any of these and are unable to regulate them through nutritional intake alone, supplementation should be considered. The nurse should discuss types of foods the client should include and limit in their diet for cardiovascular health (Table 11.4).
| Nutrient | Foods High in the Nutrient |
|---|---|
| Calcium |
|
| Potassium |
|
| Sodium |
|
| Magnesium |
|
| Fiber |
|
| Saturated fats |
|
Secondary Care Nutritional Planning
Two main diets have been shown to benefit clients with heart disease: the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet. The intent of these diets is to control weight and reduce cholesterol levels and hypertension. This approach needs to be balanced with the client’s need for protein, because malnourishment and heart failure can lead to hypoalbuminemia, a condition in which the body does not produce enough albumin, a protein that keeps fluids in blood vessels.
The nurse should consider BMI, which is calculated as weight in kilograms by height in meters squared (kg/m2) and waist size values:
- BMI—A healthy BMI is 18–24.9 kg/m2;; an overweight BMI is 25–29.9 kg/m2; and obesity is a BMI of 30 kg/m2 or higher.
- Waist size—A person who has a large waist size has a higher chance of developing cardiovascular disease, even with a normal BMI. Males should aim to keep their waist size below 40 inches (102 cm) and females should aim to keep their waist size below 35 inches (88 cm) (Harvard University, 2023).
BMI Measurement
The nurse should know a client’s BMI before creating a nutritional plan because a high BMI increases cardiovascular risks. For clients with a high BMI, weight loss should be included in the plan. Harvard Medical School provides a useful BMI calculator.
Another metric is blood pressure, which measures hypertension or the advancement of hypertension. Hypertension is known as the silent killer, because many people often do not have symptoms. Blood pressure is measured in millimeters of mercury, or mm Hg. A single high hypertension value may not indicate an issue, but two or more consecutive high readings is considered hypertension (Mayo Clinic, 2023c). Blood pressure ranges and their associated condition are listed in Table 11.5.
| Blood Pressure | Systolic | Diastolic |
|---|---|---|
| Low | < 90 mm Hg | Or < 60 mm Hg |
| Normal | < 120 mm Hg | And < 80 mm Hg |
| Elevated | 120–129 mm Hg | Or < 80 mm Hg |
| Hypertensive | > 129 mm Hg | Or > 80 mm Hg |
Cholesterol levels are also critical. Excessive cholesterol levels can lead to the buildup of plaques along blood vessels, resulting in restricted blood flow and leading to hypertension, peripheral vascular and artery disease, and cardiomyopathies, and can cause embolizing events in the body. Table 11.6 outlines ranges of cholesterol measurements and their meanings (Johns Hopkins Medicine, 2023a).
| Cholesterol Measurement | Near Optimal mg/dL |
Optimal mg/dL |
Normal mg/dL |
Borderline High mg/dL |
High mg/dL |
Very High mg/dL |
|---|---|---|---|---|---|---|
| Total cholesterol | < 200 | 200–239 | > 239 | |||
| Low-density lipids (LDL) (“bad” cholesterol) | 100–129 | < 100 | 130–159 | 160–189 | > 189 | |
| Triglycerides | < 150 | 150–199 | 200–499 | > 499 | ||
| High-density lipids (HDL) (“good” cholesterol) | > 60 | > 40 |
Unfolding Case Study
Part B
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Part A.
Mr. Thompson has returned for his one-week follow-up. His cholesterol values are:
- Total cholesterol: 269 mg/dL
- LDL: 139 mg/dL
- HDL: 130 mg/dL
His blood pressure is 133/87 mm Hg, and his weight has increased by 2 lb. The nurse calculates his BMI to be 21 kg/m2 and his waist size is 42 inches.
The nurse discusses the dietary choices that Mr. Thompson can recall eating in the last few days and discovers that he is not eating a heart-healthy diet. The nurse makes suggestions for other food choices, and the provider refers Mr. Thompson to a dietitian for further education and nutritional management. He is asked to schedule a follow-up appointment in 3 months. At that time, the provider will determine if these changes have been effective enough or if medications will need to be added to his treatment plan.
Identifying Challenges to Nutritional Goals
Motivation, food security, financial resources, disability, and comprehension are additional factors that impact cardiovascular health. Motivation is a significant factor because behavior changes may be needed, and the client may need help maintaining their health plan. For example, the client may need to learn a new diet that includes food they feel is lacking in taste, start exercising, or quit smoking. The client will have to truly desire to make changes.
The second major factor that can impact nutritional goals is access to the foods required in the nutritional plan (meal plan) created for the client. Healthy foods like fresh fruits and vegetables cost more and do not last as long as processed unhealthy food. This can be difficult for a client who is already financially or geographically challenged. Frozen fruits and vegetables are another potential healthy source that will last longer than fresh varieties, but they are still more expensive. These also require the client to have storage for these that they may not have, depending on their living situation. Canned fruits and vegetables are the least expensive options they could add to their diet, but they are also the least healthy. They may be prepared with large amounts of salt and sugar, and this will outweigh the benefits the client will obtain from eating them. Even low-sodium and low-sugar options are higher in salt and sugar than fresh options are.
A third major factor is the client’s ability to understand the nutritional plan. The client must fully understand what foods are on the diet plan, how to properly read food labels, and how to make appropriate substitutions and measurements. If they do not have a firm understanding, they may struggle to follow the plan. It may be necessary to refer the client to a registered dietician and follow up consistently to ensure the client both understands the education given and is adhering to the recommendations.
Lastly, debilitating health can contribute to the challenge of cardiovascular health. In the later stages of many of diseases, shortness of breath and fatigue can make eating very difficult. It also increases the difficulty level in food preparation, making it easier for a client to revert to eating fast foods in favor of less effort. The registered dietician can offer some solutions regarding food preparation to reduce fatigue, such as purchasing prechopped fruits and vegetables, making sheet-pan meals, and using slow-cooker recipes. This will not alleviate the fatigue that clients with breathing difficulties will have during the act of eating. The registered dietician can take this breathing issue into account and help with the selection of more nutrient-dense foods, so that the client will have to eat less to meet their needed requirements.