1. A Case of Comorbidities
STEPHANIE RICHARDSON, DIETETIC INTERN
2. Picturing the Patient
58 yo female
5’1” (1.54 m)
245 #, baseline 180# + 65# fluid overload
Admitted for systolic HF and uncontrolled DM
Admitted in September and October 2015 for CHF exacerbation.
Hx of multiple hospital admissions for HF
Hx of noncompliance with heart meds
PMH: CAD, IBS, HTN, Hyperlipidemia, Diabetic Neuropathy, GERD
Current Medical Conditions: Obesity Class 3, Uncontrolled DMT2,
systolic HF
5. Food Consumption
Sister prepares with no added salt.
Knowledgeable about CHO counting and eats q 3-4 h.
Recall high in processed/cured meats, refined grains, some convenience
food.
Low F/V intake.
Drinks 3-4 sodas q day.
Drinks 2 glasses of milk q day + tea/water.
7. Diet Order/ Nutrition Prescription
1665-2220 kcal/kg (15-20 kcal/kg —current body wt)
50-60 g/kg (1-1.2 g/kg IBW)
Low Fat diet, 2 g Na restriction, 1.5 L fluid restriction
8. PES
Food and nutrient knowledge deficit
related to lack of understanding of how
to apply information as evidenced by
A1C of 12.1% and pt stating uncertainty
of what constitutes good snacks for a
diabetic.
9. F/U
Pt had difficulty recalling what foods are high in CHO and needed
prompting.
Pt’s goal upon discharge is to limit soda intake to maximum of 1 per day.
Third time’s the charm: Pt finally seems ready to make dietary changes.
10. Obesity to DMT2
Obesity creates lipotoxic environment due to
excessive adipose tissue
Adipose tissue = metabolically active organ
Controls FFA levels
Contributes to metabolic homeostasis by
secreting adipokines
Obesity causes recruitment of immune cells and
promotes inflammation = local insulin resistance
Uncontrolled release of FFA
Altered balance of adipokines
Secretion of pro-inflammatory cytokines
11. Obesity to CHF
Obesity promotes CVD b/c excessive adipose
tissue releases pro-inflammatory adipokines +
renin, angiotensinogen, & angiotensin 2
These metabolites promote HTN
Inflammation + HTN put extra stress on heart
muscle
Result = weakness + reduced function, and finally
CHF
12. Heart Ed: Salt AND Sugar
CVD = leading cause of premature mortality in developed world
HTN = major risk factor; usually treated with low sodium diet
Noted contributor= processed foods
High in sodium
High in added sugar, especially fructose
Should cardiac nutrition education evolve to specifically address
added sugar (sucrose)?
13. Study (Yang et al, 2014)
Added Sugar Intake and Cardiovascular Diseases Mortality
NHANES trend analysis from 1988-1994 (n=11,733), 1999-2004 (n=8,786),
and 2005-2010 (n=10,628)
~15% kcal from added sugar = average intake
Majority consumed 10%+ kcal from added sugar
10% consumed 25%+ kcal from added sugar
8% of kcal vs 17-21% of kcal >> latter had a 38% higher risk of CVD
mortality
#1 source: SSB (37%); #2: grain-based desserts (13.7%); #3: fruit drinks
(8.9%)
14. Study
Overall diet quality did not change association between added sugar/CVD mortality
Healthy Eating Index
Biological mechanisms still being understood
High added sugar >> HTN, increased TG, increased LDL-C, decreased HDL-C
High added sugar >> associated with inflammatory markers
Limitations: 2nd day 24 h recalls; added sugar baseline assessment; observational study
Conclusion: positive association between added sugar & CVD mortality
Significant AFTER adjusting for CVD risk factors (BP, total serum cholesterol)
Observations observed across age groups, sex, race, education, PA, BMI
Study (Yang et al, 2014)
15. Review (Malik et al, 2010)
Sugar-Sweetened Beverages, Obesity, Type 2 Diabetes Mellitus, and Cardiovascular
Disease Risk
Large epidemiological studies show high added sugar intake =
Wt gain >> obesity
High dietary glycemic load from fructose >> insulin resistance, impaired B-cell
function >> T2DM & CVD
DM: 50,00 women over 8 y. period consuming ≥ 1 SSB/day had 83% greater risk of
developing T2DM vs those consuming <1 SSB/month (+ more studies)
CVD: 6,154 adults over 4 y. period consuming ≥ 1 soft drink/day had 22% higher
incidence of HTN vs nonconsumers (+ more studies)
Inflammation: Positive associations between SSBs and high CRP levels
FYI: caramel coloring in Cola = high in advanced glycation end products >> can
increase insulin resistance and inflammation
16. Review (Malik et al, 2010)
Sucrose (added sugar) = Fructose + Glucose
Fructose
More adverse effects than glucose d/t different metabolic pathway
Fructose + Glucose = power combo
Fructose alone = poorly absorbed>> absorption enhanced by glucose
Added sugar (sucrose) & HFCS } both combos of F+G
Liver
Fructose preferentially metabolized to lipid
Causes increased TG >> associated with insulin resistance & CVD
Conclusion: SSB intake is increasing; sig. to wt gain + T2DM + CVD
17. References
Yang Q, Zhang Z, Gregg EW, Flanders W, Merritt R, Hu FB. Added Sugar Intake and
Cardiovascular Diseases Mortality Among US Adults. JAMA Intern Med.
2014;174(4):516-524. doi:10.1001/jamainternmed.2013.13563.
Malik VS, Popkin BM, Bray GA, Després JP, Hu FB. Sugar-sweetened beverages,
obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation.
2010;121(11):1356-1364.
