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Diabetes Mellitus & Hypertension

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1 Diabetes Mellitus & Hypertension

2 What is diabetes? Diabetes is a disease in which levels of blood glucose, also called blood sugar, are above normal. People with diabetes have problems converting food to energy. Normally, after a meal, the body breaks food down into glucose, which the blood carries to cells throughout the body. Cells use insulin, a hormone made in the pancreas, to help them convert blood glucose into energy.

3 What is diabetes? People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly, or both. As a result, the amount of glucose in the blood increases while the cells are starved of energy. Over the years, high blood glucose, also called hyperglycemia, damages nerves and blood vessels, which can lead to complications such as heart disease, stroke, kidney disease, blindness, nerve problems, gum infections, and amputation.

4 Main Types of Diabetes Two main types of diabetes are called type 1 and type 2. A third form of diabetes is called gestational diabetes.

5 Type 1 diabetes, formerly called juvenile diabetes
Usually first diagnosed in children, teenagers, and young adults. In this form of diabetes, the pancreas no longer makes insulin because the body’s immune system has attacked and destroyed the pancreatic cells specialized to make insulin. These insulin-producing cells are called beta cells.

6 Type 2 diabetes, formerly called adult-onset diabetes
Most common form. People can develop type 2 diabetes at any age, even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin properly. As a result, the body needs more insulin to help glucose enter cells to be used for energy. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, the pancreas loses its ability to secrete enough insulin in response to meals.

7 Gestational diabetes Diabetes that first occurs during pregnancy.
When women are pregnant, their need for insulin appears to increase, and many can develop gestational diabetes during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life.

8 Other Types of Diabetes
Genetic defects of the beta cell, such as maturity-onset diabetes of the young (MODY) and neonatal diabetes mellitus Genetic defects in insulin action, resulting in the body’s inability to control blood glucose levels, as seen in leprechaunism and the Rabson-Mendenhall syndrome Diseases of the pancreas or conditions that damage the pancreas, such as pancreatitis and cystic fibrosis Excess amounts of certain hormones resulting from some medical conditions—such as cortisol in Cushing’s syndrome —that work against the action of insulin Medications that reduce insulin action, such as glucocorticoids, or chemicals that destroy beta cells Infections, such as congenital rubella and cytomegalovirus Rare autoimmune disorders, such as stiff-man syndrome, an autoimmune disease of the central nervous system Genetic syndromes associated with diabetes, such as Down syndrome and Prader-Willi syndrome

9 Type 1 and type 2 diabetes

10 What is pre-diabetes? In pre-diabetes, blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Experts disagree about the specific blood glucose level they should use to diagnose diabetes, and through the years, that number has changed. Individuals with pre-diabetes have an increased risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.

11 How are diabetes and pre-diabetes diagnosed?
The following tests are used for diagnosis: A fasting plasma glucose (FPG) test measures blood glucose in a person who has not eaten anything for at least 8 hours. This test is used to detect diabetes and pre-diabetes. An oral glucose tolerance test (OGTT) measures blood glucose after a person fasts at least 8 hours and 2 hours after the person drinks a glucose-containing beverage. This test can be used to diagnose diabetes and pre-diabetes. A random plasma glucose test, also called a casual plasma glucose test, measures blood glucose without regard to when the person being tested last ate. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes. Test results indicating that a person has diabetes should be confirmed with a second test on a different day.

12 FPG Test Preferred test for diagnosing diabetes because of its convenience and low cost. Most reliable when done in the morning However, it will miss some diabetes or pre-diabetes that can be found with the OGTT. People with a fasting glucose level of 100 to 125 milligrams per deciliter (mg/dL) have a form of pre-diabetes called impaired fasting glucose (IFG). Having IFG means a person has an increased risk of developing type 2 diabetes but does not have it yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means a person has diabetes. Results and their meaning are shown in Table 1.

13 Table 1 - FPG Test *Confirmed by repeating the test on a different day

14 Oral Glucose Tolerance test (OGTT)
Research has shown that the OGTT is more sensitive than the FPG test for diagnosing pre-diabetes, but it is less convenient to administer. The OGTT requires fasting for at least 8 hours before the test. The plasma glucose level is measured immediately before and 2 hours after a person drinks a liquid containing 75 grams of glucose dissolved in water.

15 OGTT Results and their meaning are shown in Table 2.
If the blood glucose level is between 140 and 199 mg/dL 2 hours after drinking the liquid, the person has a form of pre-diabetes called impaired glucose tolerance (IGT). Having IGT, like having IFG, means a person has an increased risk of developing type 2 diabetes but does not have it yet. A 2-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means a person has diabetes.

16 Table 2 - OGTT Test *Confirmed by repeating the test on a different day.

17 Gestational diabetes Also diagnosed based on plasma glucose values measured during the OGTT, preferably by using 100 grams of glucose in liquid for the test. Blood glucose levels are checked four times during the test. If blood glucose levels are above normal at least twice during the test, the woman has gestational diabetes. Table 3 shows the above-normal results for the OGTT for gestational diabetes.

18 Table 3. Gestational diabetes: Above-normal results for the OGTT*
Note: Some laboratories use other numbers for this test. *These numbers are for a test using a drink with 100 grams of glucose.

19 Random Plasma Glucose Test
A random, or casual, blood glucose level of 200 mg/dL or higher, plus the presence of the following symptoms, can mean a person has diabetes: Increased urination Increased thirst Unexplained weight loss Other symptoms can include fatigue, blurred vision, increased hunger, and sores that do not heal. The doctor will check the person’s blood glucose level on another day using the FPG test or the OGTT to confirm the diagnosis.

20 Who should be tested for diabetes and pre-diabetes?
The American Diabetes Association recommends that testing to detect pre-diabetes and type 2 diabetes be considered in adults without symptoms who are overweight or obese and have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45. The Body Mass Index Table can be used to find out whether someone is normal weight, overweight, obese, or extremely obese.

21 Body Mass Index

22 The BMI has certain limitations
It may overestimate body fat in athletes and others who have a muscular build and underestimate body fat in older adults and others who have lost muscle. BMI for children and teens must be determined based on age, height, weight, and sex. The Centers for Disease Control and Prevention (CDC) has information about BMI in children and teens, including a BMI calculator, at The CDC website also has a BMI calculator for adults.

23 Body Mass Index

24 Waist measurement In addition to weight, the location of excess fat on the body can be important. A waist measurement of 40 inches or more for men or 35 inches or more for women is linked to insulin resistance and increases a person’s risk for type 2 diabetes.

25 Being physically inactive
People aged 45 or older should consider getting tested for pre-diabetes or diabetes. People younger than 45 should consider testing if they are overweight, obese, or extremely obese and have one or more of the following risk factors: Being physically inactive Having a parent, brother, or sister with diabetes Having a family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander Giving birth to a baby weighing more than 9 pounds or being diagnosed with gestational diabetes Having high blood pressure—140/90 mmHg or above—or being treated for high blood pressure Having an HDL, or “good,” cholesterol level below 35 mg/dL or a triglyceride level above 250 mg/dL Having polycystic ovary syndrome, also called PCOS Having IFG or IGT on previous testing Having a condition called acanthosis nigricans, characterized by a dark, velvety rash around the neck or armpits Having a history of cardiovascular disease—disease affecting the heart and blood vessels

26 Diabetes testing If results of testing are normal, testing should be repeated at least every 3 years. Doctors may recommend more frequent testing depending on initial results and risk status. People whose test results indicate they have pre-diabetes should have their blood glucose checked again in 1 to 2 years and take steps to prevent type 2 diabetes.

27 Diabetes testing When a woman is pregnant, the doctor will assess her risk for developing gestational diabetes at her first prenatal visit and order testing as needed during the pregnancy. Women who develop gestational diabetes should also have follow-up testing 6 to 12 weeks after the baby is born.

28 Diabetes testing Type 2 diabetes has become more common in children and teens than in the past, and those at high risk for developing diabetes should be tested every 2 years. Testing should begin at age 10 or at puberty, whichever occurs first. Children and teens who are overweight or obese and have other risk factors, such as a family history of diabetes, are at high risk for developing diabetes.

29 What steps can delay or prevent type 2 diabetes?
A major research study, the Diabetes Prevention Program (DPP), confirmed that people with IGT—pre-diabetes—were able to sharply reduce their risk of developing diabetes during the study by losing 5 to 7 percent of their body weight through dietary changes and increased physical activity. Study participants followed a low-fat, low-calorie diet and engaged in regular physical activity, such as walking briskly for 30 minutes, five times a week. These strategies worked well for both men and women and were especially effective for participants aged 60 and older.

30 More information about insulin resistance, the DPP, or how to lower risk for type 2 diabetes is available in the following publications: Insulin Resistance and Pre-diabetes Diabetes Prevention Program (DPP) Am I at Risk for Type 2 Diabetes?

31 These publications are available at www. diabetes. niddk. nih
These publications are available at or by calling 1–800–860–8747. The National Diabetes Education Program (NDEP) offers several booklets as part of its Small Steps, Big Rewards campaign on preventing type 2 diabetes, including information about setting goals, tracking progress, implementing a walking program, and finding additional resources. These materials are available at or by calling the NDEP at 1–888–693–NDEP (6337).

32 Points to Remember Diabetes, pre-diabetes, and gestational diabetes are diagnosed by checking blood glucose levels. Tests used for diagnosing diabetes and pre-diabetes include the fasting plasma glucose (FPG) test and the oral glucose tolerance test (OGTT). People aged 45 or older should consider getting tested for pre-diabetes or diabetes. People younger than 45 who are overweight, obese, or extremely obese and have one or more additional risk factors for diabetes should consider testing. Many people with pre-diabetes develop type 2 diabetes within 10 years. People with pre-diabetes can delay or prevent type 2 diabetes by losing a modest amount of weight through regular physical activity and a diet low in fat and calories

33 Monitoring the Blood Glucose levels

34 Monitoring the Blood Glucose levels
Why blood glucose is monitored When blood glucose should be monitored How to perform a blood glucose check

35 Blood sugar testing: Why, when and how
When you have diabetes, blood sugar testing is the most important thing you can do to feel your best and prevent long-term complications. Consider it an opportunity to take charge of your health.

36 Target Ranges Keeping your blood sugar in range will lower your risk of complications Blindness Heart disease Kidney problems Sexual dysfunction Nerve damage

37 Why Check Your Blood Sugar?
Checking your blood sugar every day can help you learn how well your medication is working how different foods affect your blood sugar how exercise affects you blood sugar why you are having highs and lows

38 Know your target range Your doctor will set your target blood sugar range. For many people who have diabetes, target levels are: Fasting at least eight hours (fasting blood sugar level) — between 90 and 130 milligrams per deciliter (mg/dL) or 5 and 7 millimoles per liter (mmol/L) Before meals — between 70 and 130 mg/dL (4 and 7 mmol/L) One to two hours after meals — lower than 180 mg/dL (10 mmol/L)

39 Know your target range Remember that your target blood sugar range may differ, especially if you're pregnant or you develop diabetes complications. Your target blood sugar range may change as you get older, too. Sometimes reaching your target blood sugar range is a challenge. But the closer you get, the better you'll feel.

40 When to test your blood sugar
How often you test blood sugar levels depends on many factors, including the type of diabetes you have, your individual diabetes treatment plan, and how well your blood sugar is controlled.

41 Type 1 diabetes Your doctor may recommend blood sugar testing at least three times a day — perhaps before and after certain meals, before and after exercise, and before bed. You may need to check your blood sugar level more often if you're ill or you change your daily routine.


43 Type 2 diabetes If you take insulin to manage type 2 diabetes, your doctor may recommend blood sugar testing one to three times a day, depending on the number of insulin doses you take. If you manage type 2 diabetes with other medications or with diet and exercise alone, you may be able to test your blood sugar level less often.


45 Extra checks may be necessary:
Periods of stress or illness Hypoglycemia or hyperglycemia symptoms Change in diabetes management Insulin/medication doses Meal plan Activity

46 Remember….. Check blood sugar when you suspect a low!

47 Hypoglycemia Blood sugar less than 70 Symptoms include shaking
sweating nervousness feeling irritable blurry vision or headache feeling tired no symptoms

48 Treatment of Hypoglycemia
Have one portion of fast-acting sugar 4 oz fruit juice 3 glucose tablets or 1 tube glucose gel 1 tablespoon honey or sugar Wait 15 minutes. Recheck blood sugar. If blood sugar is still less than 70 repeat. If blood sugar is above 70 eat a snack or meal within 1 hour.

49 What Makes Blood Sugars Go Down?
Diabetes pills Insulin Exercise

50 What Makes Blood Sugars Go Up?
Food Not enough diabetes pills/insulin Certain medicines Infection/sickness Surgery Stress Menstrual period

51 How to test your blood sugar
Blood sugar testing requires a blood sugar monitor. Some monitors are large with easy-to-handle test strips, while others are compact and easier to carry. Some monitors track the time and date of each test, the result and trends over time.

52 Know the Meter Features vary: Ease of use Sample size needed Wait time
Alternate-site testing capacity Ability to reapply, if insufficient sample Many meters available on market. If you're unsure which blood sugar monitor is best, ask your doctor or diabetes educator for a recommendation. There are many reliable meters on the market. Each has a unique set of features and operating procedures. A number of features vary from meter to meter. Some of the features are convenience-based. Others can be critical to accuracy in test results. Ease of use Sample size needed Ability to reapply, if insufficient sample Wait time Alternate-site testing capacity Work with parent to become familiar with the operation of student’s particular meter. Every blood glucose meter has a number on the back to call for questions about meter and to obtain technical support. 52 52

53 Lancing Devices Lancets Pen-type Lancing Devices
The basic tool for drawing blood for a glucose check is the lancet, a very sharp steel blade in a plastic case. There are many types of lancets and lancet devices. Many students will use a lancing device, a pen-shaped lancet holder that "launches" the blade with a spring and controls the depth of the puncture. Some lancing devices (like the one pictured at the bottom of the screen) have several depth settings to allow for the difference between sensitive fingers and callused fingers. Some come with two caps for the end that touches the finger to adjust the depth of puncture. In addition, the pressure of the finger on the cap determines how deep the puncture will go. It should be deep enough to provide an adequate amount of blood, but not be so deep as to cause bruising or pain. Lancets should be disposed of after use in a sharps disposal container as per student’s education plan and local ordinances. 53 53

54 To test your blood sugar, follow the instructions that come with your glucose meter. In general, here's how the process works: Before pricking your finger, wash your hands with soap and warm water. Then dry them well. Remove a test strip from the container and replace the cap immediately to prevent damage to the strips. Insert the test strip into the meter. Place the tip of the special needle (lancet) on your finger. Stick the side of your finger, not the tip, so that you won't have sore spots on the part of your finger you use the most. Hold your hand down to encourage a drop of blood to form. When you have a drop of blood, carefully touch the test strip to the blood (avoid touching your skin with the test strip) and wait for a reading. Within a few seconds, the meter will display your blood glucose level on a screen.

55 Lancing the Finger Hold the lancet device to the side of the finger and press the button to stick the finger. Instructions: 7. Hold the lancet device to the side of the finger and press the button to stick the finger. Express an adequate drop of blood. 55 55

56 Applying Blood to Strip
Follow instructions included with the meter when applying blood to strip Instructions: 8. How blood is applied to the strip is a little different from meter to meter. Follow instructions included with the meter in how to apply the blood sample. This slide shows three different kinds of strips to illustrate some things to keep in mind. With the first type of meter & strip, on the left: Be sure to drop, do not smear the blood onto the strip. With all meters and strips, be sure to completely cover the test strip window. The picture on the right illustrates that some strips actually suck the blood onto the strip by capillary action upon contact with the drop of blood on the finger (or other alternate site). Cover ALL of test strip window Some strips suck blood onto the strip Drop, not smear 56

57 Readying the Meter Instructions:
Turn the meter on if necessary. Some meters turn on automatically when the strip is inserted. Check code number that appears on meter with the code number found on the container of the test strips. Correct meter code if codes do not match. Insert a strip into the meter (some meters turn on automatically when the strip is inserted). 57

58 Results Wait. Blood glucose results will be displayed on the meter. Meter processing times vary. Most will take from 15 seconds to one minute. Dispose of the lancet in sharps container as per student’s education plan and local ordinances. Never recap. Test strips may be discarded in a regular trash can. Record blood glucose result 250 53 Instructions: 9. 58 58

59 Your fingertips contain a lot of nerve endings, so make sure to rotate the sites where you stick your fingers. If you have a newer glucose meter, you'll have the option to test your blood glucose from other sites, such as your forearm or thigh. But check with your doctor or diabetes educator first to find out if alternative site testing is appropriate in your case.

60 Recording your results
Each time you perform a blood test, log your results. Record the date, time, test results, medication and dosage, and diet and exercise information in a notebook, record book or journal. Better yet, you may be able to download the information to your computer or transfer the information to a mobile device or an online tracking program. The more complete your records are, the more useful they'll be.

61 This information helps you see how food, physical activity, medication and other factors affect your blood glucose. As patterns occur, you can begin to understand how your daily activities affect your blood sugar levels. This puts you in a better position to manage your diabetes day by day and even hour by hour.

62 If your blood sugar readings are consistently higher or lower than your target range — or blood sugar extremes don't respond to adjustments in diet or medication — you may need to revise your treatment plan. In some cases, your doctor may suggest changing your diet or including more physical activity in your daily routine. If that's not effective, you may need to take medication or adjust your medication dosage.

63 Hypertension HTN = abnormal elevation of BP Normal <120/80
PreHTN /80-89 Stage /90-99 Stage 2 >160/100

64 Why do we care? Relationship b/w BP and Cardiovascular disease is positive and continuous. We want to prevent: Stroke, MI, HF, kidney damage, retinopathy, peripheral artery dz, other morbidity of atherosclerosis

65 Does treatment help? YES 35-40% decline in stroke
25% decline in Coronary artery disease/Myocardial Infarction >50% decline in Heart Failure

66 Diagnosis and Tests for Hypertension
Blood pressure is measured or tested by taking a blood pressure reading. It is measured using two numbers, (i.e.120/80mmHg). The "top" number is called the systolic number, which is a measurement of the pressure on the artery walls when the heart beats. The "bottom" number is the diastolic number, which is a measurement of the pressure on the artery walls when the heart is resting between beats.

67 The list of diagnostic tests mentioned in various sources as used in the diagnosis of Hypertension includes: Sphygmomanometer (arm cuff blood pressure test) Home blood pressure tests Finger cuff blood pressure test

68 Diagnosis of HTN Repeated abnormal elevation of BP using proper technique/cuff on 3 separate occasions over at least 6 weeks A single blood pressure >200/120 Keep in mind: – Risk factors – Evidence of end-organ disease

69 BP readings at 2 to 3 separate appointments
Blood pressure normally varies throughout the day — and sometimes specifically during visits to the doctor, a condition called white-coat hypertension. Your doctor may ask you to record your blood pressure at home and at work to provide additional information. Measuring your blood pressure at home can also help diagnose masked hypertension, a condition in which your blood pressure is lower than it normally is when you visit the doctor's office.

70 Home measurement of blood pressure
Increases patient self-efficacy and is recommended. More reliably predict the risk of cardiovascular outcomes than readings taken in a health care professional’s office. Can be used to confirm the diagnosis of hypertension, to improve blood pressure control, to reduce the need for medications in those with white coat effect, to identify those with white coat and masked hypertension and to improve medication adherence

71 Hypertension Home Blood Pressure Monitoring Mercury sphygmomanometer
Standard for BP monitoring No calibration May be bulky Need a second person to use machine May be difficult for hearing impaired or patients with arthritis

72 Hypertension Home Blood Pressure Monitoring Aneroid equipment
Inexpensive, lightweight and portable Two person operation/need stethoscope Delicate mechanism, easily damaged Needs calibration with mercury sphygmomanometer

73 Hypertension Home Blood Pressure Monitoring Automatic equipment
Contained in one unit Portable with easy-to-read digital display Expensive, fragile Must be calibrated Requires careful cuff placement

74 If you have any type of high blood pressure, your doctor may recommend routine tests, such as a urine test (urinalysis), blood tests and an electrocardiogram (ECG) — a test that measures your heart's electrical activity. More extensive testing isn't usually needed, at least initially.

75 High Blood Pressure (Hypertension) - Prevention
Lifestyle changes can help you prevent high blood pressure. These changes are especially important for people who have risk factors for high blood pressure that cannot be changed, including family history, race, or age.

76 Lifestyle changes include:
Staying at a healthy weight, with a body mass index (BMI) of 18.5 to 24.9. Reducing sodium in your diet to less than 2,300 mg a day, which is about 1 teaspoon of salt. Exercising, such as brisk walking, that raises your heart rate. Aim for at least 2½ hours of moderate exercise a week. Limiting alcohol drinks to 2 drinks a day for men and 1 drink a day for women. Abstaining from cigarette smoking Following the Dietary Approaches to Stop Hypertension (DASH) eating plan, a diet that is rich in fruits, vegetables, and low-fat dairy products, with reduced amounts of saturated and total fats.

77 Relaxation therapy Reducing stress, for example with relaxation therapy, such as meditation and other mind body relaxation techniques, by reducing environmental stress such as high sound levels and over-illumination can also lower blood pressure

78 Life style modifications for all pts
Decrease weight: lowers BP 5-20mmHg/10 Kg DASH diet: 8-14 mmHg Low Na diet: 2-8 mmHg Aerobic exercise: 4-9 mmHg Decrease Et OH (Alcohol): 2-4 mmHg

79 High blood pressure: Using the DASH diet
The DASH diet is an eating plan that is low in fat but rich in low-fat dairy foods, fruits, and vegetables. DASH stands for Dietary Approaches to Stop Hypertension. DASH diet - lowers blood pressure. Prevents high blood pressure if you have pre hypertension (your blood pressure is between 120–139 over 80–89) This diet is also linked to a lower risk of heart disease and stroke

80 DASH DASH also recommends eating whole grains, fish, poultry, nuts, seeds, and dried beans (legumes) as part of a balanced diet. Your doctor may also want you to decrease the amount of sodium and sodium-rich prepared foods in your diet. Lowering sodium while following DASH can lower blood pressure even further than just DASH alone. You can cut down on your salt (sodium) intake by using a salt substitute. Talk to your doctor before trying a salt substitute.

81 Salt substitute To make your own salt substitute, mix the following ingredients together and put them in a shaker: 0.5tsp (2.5g) cayenne pepper 0.5tsp (2.5g) garlic powder 1tsp (5g) each: Basil Onion powder Black pepper Parsley Mace Sage Marjoram Savory Thyme Talk to your doctor before trying a salt substitute.

82 Key points: Eating fewer processed foods, such as snack items, luncheon meats, and canned soups, will reduce the amount of sodium in your diet and help you lower your blood pressure. A diet high in calcium, potassium, and magnesium may lower your blood pressure. A diet high in sodium may cause high blood pressure.

83 Key points: To increase the potassium in your diet, fruits and vegetables are excellent sources of this nutrient. Dairy products are high in calcium and magnesium. DASH recommends that you eat 8 to 10 servings of fruits and vegetables and 3 servings of low-fat dairy products each day.

84 Key points: Eating a diet low in both saturated fat and total fat will also help lower your blood pressure. Only 30% of your total calories should be from fat, with only 7% to 10% of your fat calories from saturated fat. Saturated fat is found in meats, cheeses, butter, poultry, snack foods, and other processed foods.

85 Key points: Vegetarian diets reduce blood pressure
The DASH diet could easily be a vegetarian diet if legumes were substituted for meat. Vegetarian diets tend to be higher in potassium, magnesium, and calcium, as is the DASH diet. Vegetarian diets also are higher in fiber and unsaturated fat than other diets. Controlling your weight, increasing your physical activity, and reducing sodium in your diet will help reduce your blood pressure even more when combined with the DASH diet.

86 Good sources of potassium
All fresh fruits and vegetables and meats are good sources of potassium. Fruit and vegetable examples include: Bananas, cantaloupe, oranges, and orange juice. Raw or cooked spinach, lima beans, zucchini, broccoli, carrots, cauliflower, and artichokes. Potatoes. Legumes (cooked dried beans and peas) such as pinto beans, chickpeas, and lentils.

87 Ask your doctor to recommend a registered dietitian who can work with you to change your eating habits and help you plan menus that follow the DASH eating style.

88 Sample menu for the Dietary Approaches to Stop Hypertension (DASH) diet
Breakfast 1 cup corn flakes with 1 teaspoon of sugar 8 ounces low-fat milk 1/2 banana 1 slice whole wheat toast 1 tablespoon jelly 4 ounces orange juice Lunch 2 ounces sliced turkey 1 pita bread 1 tablespoon low-fat mayonnaise Raw vegetables: 3 or 4 carrot sticks, celery sticks, radishes, 2 loose lettuce leaves 1/2 cup fruit cocktail Snack 1/4 cup dried apricots 3/4 cup mini-pretzels 1/3 cup mixed nuts 1 cup flavored low-fat yogurt Dinner 3 ounces grilled salmon 1 cup scallion rice 1 cup steamed broccoli Spinach salad with 1 cup raw spinach, 2 cherry tomatoes, 2 cucumber slices 1 tablespoon light Italian dressing 8 ounces low-fat chocolate milk

89 Track your eating habits
Record everything you eat before you start DASH, charting the number of servings you eat in the following food groups: grains; vegetables; fruits; dairy; meats (including poultry and fish); nuts, seeds, and beans; fats and oils; and sweets. As well as you can, record the amount of sodium in everything you eat. After you begin the DASH eating plan, keep the same charts, and compare your lists.

90 For more sample menus and recipes for the DASH eating plan, contact the National Heart, Lung, and Blood Institute. Go to and search for DASH. Or go to Or write to the NHLBI Health Information Center, P.O. Box 30105, Bethesda, MD , and request information on the DASH diet.

91 Early diagnosis of Hypertension
Diagnosed on the basis of a persistently high blood pressure. Usually this requires three separate sphygmomanometer measurements at least one week apart. Initial assessment of the hypertensive patient should include a complete history and physical examination. Exceptionally, if the elevation is extreme, or if symptoms of organ damage are present then the diagnosis may be given and treatment started immediately.

92 Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on risk factors and other symptoms, if present.

93 Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension

94 Hypertension with Molecular Genetic techniques
Genes encoding the components of Renin angiotensin system (R-A): Which includes Angiotensinogen (AGT) M235T, angiotensin1-coverting enzyme (ACE) G2350A, (ACE) I/D , Angiotensinogen II type 1 receptor (ATR1) A1166C,and Aldosterone synthase C-344T polymorphisms

95 Polymorphisms of the angiotensinogen (AGT) gene and the angiotensin converting enzyme (ACE) gene in human essential hypertension is more common

96 Tests typically performed are classified as follows

97 Routine Laboratory Tests
Preliminary Investigations of patients with hypertension 1. Urinalysis 2. Blood chemistry (potassium, sodium and creatinine) 3. Fasting glucose 4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5. Standard 12-leads ECG Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes or kidney disease

98 Routine Laboratory Tests
Follow-up investigations of patients with hypertension During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. Diabetes develops in 1-3%/year of those with drug treated hypertension. The risk is higher in those treated with a diuretic or beta blocker, in the obese, sedentary, with higher fasting glucose and who have unhealthy eating patterns. Assess for diabetes more frequently in these patients.

99 Optional Laboratory Tests
Investigation for specific patient subgroups • For those with diabetes or chronic kidney disease: assess urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present. For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides. • Other secondary forms of hypertension require specific testing. Albumin : creatinine ratio [ACR] > 30 mg/mmol is abnormal

100 Additional tests Creatinine (renal function) testing - to determine if kidney disease is present, which can be either the cause or result of hypertension. Also provides a baseline measurement of kidney function that can be used to monitor for side-effects of certain antihypertensive drugs on kidney function. Testing of urine samples for protein is used as a secondary indicator of kidney disease. Glucose testing is done to determine if diabetes is present.

101 Additional tests Electrocardiogram (EKG/ECG) testing is done to check for evidence of the heart being under strain from high blood pressure. It may also show if there is thickening of the heart muscle (left ventricular hypertrophy) or has experienced a prior minor heart disturbance such as a silent heart attack. A chest X-ray may be performed to look for signs of heart enlargement or damage to heart tissue

102 Screening for Renovascular Hypertension
Patients presenting with two or more of the following clinical clues listed below suggesting renovascular hypertension should be investigated. sudden onset or worsening of hypertension and > age 55 or < age 30 the presence of an abdominal bruit hypertension resistant to 3 or more drugs a rise in creatinine of 30% or more associated with use of an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia recurrent pulmonary edema associated with hypertensive surges

103 Treatment Lifestyle modifications Medications – Antihypertensive drugs
ACE inhibitors such as ramipril Angiotensin II receptor antagonists may be used where ACE inhibitors are not tolerated: e.g., candesartan Calcium channel blockers such as nifedipine Diuretics: e.g. hydrochlorothiazide (aHCTZ). Diuretics such a furosemide or low-dosages of spironolactone Alpha blockers such as terazosin. Doxazosin has been shown to the increase risk of heart failure, and to be less effective than a diuretics Beta blockers such as metoprolol. Whilst once were first line agents, now they are less commonly used because they increase the risk of diabetes Direct renin inhibitors such as aliskiren

104 Criteria for the diagnosis of hypertension and recommendations for follow-up
Non Pharmacological treatment With or without Pharmacological treatment Are BP readings below target during 2 consecutive visits? Yes No Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage Follow-up at 3-6 month intervals * Yes No Visits every 1 to 2 months* More frequent visits * * Consider Home measurement in hypertension management, to screen for masked hypertension or white coat effect and to enhance adherence.

105 Complications of Hypertension

106 Search for target organ damage
Assessment of the overall cardiovascular risk Search for target organ damage Cerebrovascular disease - transient ischemic attacks - ischemic or hemorrhagic stroke - vascular dementia Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease - myocardial infarction - angina pectoris - congestive heart failure Chronic kidney disease - hypertensive nephropathy (GFR < ml/min/1.73 m2) - albuminuria Peripheral artery disease - intermittent claudication

107 Hypertension – risk factor
Hypertension is the most important risk factor for death in industrialized countries. It increases hardening of the arteries thus predisposes individuals to heart disease, peripheral vascular disease, and strokes Types of heart disease that may occur include: heart attack, heart failure, and left ventricular hypertrophy Other complications include: Hypertensive retinopathy Hypertensive nephropathy If blood pressure is very high hypertensive encephalopathy may result.

108 Hypertensive heart disease
Heart disease caused by high blood pressure, especially localized high blood pressure. Conditions that can be caused by hypertensive heart disease include: Left ventricular hypertrophy Coronary heart disease (Congestive) heart failure Hypertensive cardiomyopathy Cardiac arrhythmias

109 Treatment of heart disease
Depends on the conditions that are present (acute myocardial infarction, angina, heart failure, and so on). Pharmacotherapy: thiazide diuretics, beta-blockers and combined alpha- and beta-blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, and direct vasodilators such as hydralazine.

110 Pharmacotherapy Thiazide-type diuretics should be used for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes Calcium channel blockers are effective for systolic hypertension in elderly patients. ACE inhibitors are the first choice in patients with diabetes and/or V dysfunction. Beta-blockers are the drugs of first choice in patients with heart failure due to systolic LV dysfunction, patients with ischemic heart disease with or without a history of myocardial infarction, and in patients with thyrotoxicosis.

111 Treatment of LVH LVH, a marker of increased risk of cardiovascular morbidity and mortality, should be treated aggressively. Whether regression in LVH leads to improvement in cardiovascular mortality and morbidity rates is not clear, although limited data support this hypothesis.

112 Treatment of LVH All the medications already listed for the treatment of hypertension have been shown to reduce LVH. Limited meta-analysis data suggest a slight advantage to ACE inhibitors.

113 Treatment of LV diastolic dysfunction
Certain classes of antihypertensives —ACE inhibitors, beta-blockers, and nondihydropyridine calcium channel blockers—have been shown (although not consistently) to improve echocardiographic parameters in symptomatic and asymptomatic diastolic dysfunction and the symptomatology of heart failure.

114 Treatment of LV systolic dysfunction
Diuretics (predominantly loop diuretics) are used in the treatment of LV systolic dysfunction. ACE inhibitors are used for preload and afterload reduction and prevention of pulmonary or systemic congestion

115 Treatment of cardiac arrhythmias
Treatment depends upon the specific arrhythmia and the underlying LV function Anticoagulation should be considered in patients with atrial fibrillation. Treatment of anxiety, stress, sleep apnea, and other contributing or precipitating factors.

116 Citations Elmer PJ, et al. (2006). Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Annals of Internal Medicine, 144(7): 485–495. Fung TT, et al. (2008). Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Archives of Internal Medicine, 168(7): 713–720.


118 Thank you

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