Quick Reference Guide to Diabetes for Health Care Providers

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Quick Reference Guide to Diabetes for Health Care Providers
Revised Nov08
A special project of the Michigan Diabetes Outreach Network

Chapter 13

Diabetes and Hypertension

Hypertension (HTN) is twice as common in persons with diabetes compared to the general population. For persons with diabetes, HTN contributes to the development and progression of chronic complications, such as retinopathy, chronic kidney disease and peripheral vascular disease. Achieving and maintaining normal blood pressure levels can also minimize the risk of developing these complications. Controlling HTN begins with detection and diagnosis. Health care professionals are strongly encouraged to check blood pressure at each visit. Following proper blood pressure monitoring technique is essential to obtain accurate blood pressure readings.

*Table on Diagnosis, Classification and Treatment of Blood Pressure

If systolic and diastolic BP fall into two separate categories, use the higher category status.
*Cardiovascular Risk Factors = hypertension, cigarette smoking, obesity (BMI > 30), physical inactivity, dyslipidemia, diabetes, microalbuminuria, age (over 55 for men; over 65 for women), family history of premature cardiovascular disease (men under age 55 or women under age 65).
**TOD/CCD = Target Organ Damage and Clinical Cardiovascular Disease. TOD includes left ventricular hypertrophy, angina, prior myocardial infarction, prior coronary revascularization, heart failure, stroke or transient ischemic attack, chronic kidney disease, peripheral arterial disease or retinopathy.

According to the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) and the American Diabetes Association, the goal of treating hypertension is to achieve and maintain blood pressure less than 130/80 mmHg for persons with diabetes or chronic kidney disease.
Most persons with high blood pressure, especially those over age 50, will reach their diastolic BP goal when the systolic BP (SBP) is at goal. Therefore, the primary focus of therapy should be to achieve the systolic BP goal.

* Table on Nonpharmacological Treatment

Cigarette smoking and caffeine (> 2 cups or more of coffee) can cause a temporary, immediate rise in blood pressure; but does not impact the long-term incidence of hypertension. Additional food nutrients/components linked to improved blood pressure control are adequate intakes of soy, whole grains and folic acid.

Pharmacological Treatment

More than 2/3 of those with diabetes and HTN will require two or more different medications to achieve the goal BP of less than 130/80 mmHg. See below for evidence-based recommendations for the pharmacological treatment of diabetes and HTN.

*Table on Condition and Receommended Drug Therapy

*Table on Commonly Used Oral Antihypertensive Medications

Summary
The treatment of HTN involves considerable knowledge of the recommended lifestyle changes and medications. Because high blood pressure is often asymptomatic, lifestyle changes can be difficult to maintain. Since medications may be expensive and may have unpleasant side effects, some stop treating their high blood pressure with unfortunate results. Health care providers should explore these issues and involve the physician, as needed, to help persons with diabetes achieve their blood pressure goal. The keys are to treat hypertension aggressively and to keep blood glucose under good control to minimize the possibility of developing or exacerbating complications.
For more information on Diabetes and Hypertension, check out the Diabetes and Hypertension independent study module at www.diabetesinmichigan.org. Click on independent study modules.

References:
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, NIH Publication No. 03-5231, National High Blood Pressure Education Program, May 2003.
American Diabetes Association. Position Statement: Treatment of Hypertension in Adults with Diabetes. Practical Diabetology, March 2003.
Wylie-Rosett J. Hypertension and Diabetes: Clinical Synergy and Challenges. On the Cutting Edge, 2004: Vol 25 (4): 4-8.

*Table on DASH Eating Plan
The DASH (Dietary Approaches to Stop Hypertension) Study was a National Institutes of Health research project. Followingthe DASH Eating Plan lowered blood pressure levels in those with normal and elevated blood pressure levels without reducingsodium or using drugs. Source: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm

How to Lower Calories on the Dash Eating Plan
To increase fruits
•
Eat a medium apple instead of 4 shortbread cookies (save 80 calories).
•
Eat ¼ cup dried fruit instead of a 2 oz bag of pork rinds (save 230 calories).
To increase vegetables:
•
Have a hamburger that’s 3 oz meat instead of 6 oz. Add ½ cup of carrots and ½ cup spinach. (save 200 calories)
•
Instead of 5 oz chicken, have a stir-fry with 2 oz chicken, 1½ cup raw vegetables and 1 Tbsp oil. (save 50 calories).
•
Add fresh or frozen vegetables to soups, pastas or rice.
To increase low-fat or fat-free dairy products:
•
Drink skim milk instead of 2% milk (save 30 calories per cup) or whole milk (save 60 calories per cup).
•
Have ½ cup low-fat frozen yogurt instead of 1½ oz chocolate bar (save 110 calories).

Other calorie saving tips:
•Use low-fat or fat-free condiments.
•Use half the amount of regular vegetable oil, soft or liquid margarine or salad dressing.
•Eat smaller portions, cutting back gradually.
•Read food labels to compare fat content (low-fat and fat-free does not always mean lower in calories).
•Limit foods with lots of added sugar (pies, cakes, cookies, candy, chocolate, ice cream, sherbet, regular soft drinks and fruit drinks)
•Eat fruits canned in their own juice.
•Snack on fruit, raw vegetables or unbuttered,unsalted popcorn.
•Drink water or club soda.

Tips for reducing salt:
•Choose more fresh, unsalted foods.
•Avoid salting homemade foods. Flavor with spices.
•Read food labels and look for:
•foods with < 5% of Daily Value for sodium
•< 140 mg sodium per serving: beverages, fats, oils, meat, fish and poultry
•< 240 mg sodium per serving: snack foods, desserts, cereals, breads, grains, pasta, processed fruits and vegetables, nut butters, nuts/seeds, salad dressings or condiments
•< 600 mg sodium per serving: frozen meals, main dishes, sandwiches or fast foods.
•< 480 mg per serving: soups; all other foods

Michigan Diabetes Outreach Networks - Strengthening Diabetes Care in Michigan

MDON is funded by a grant from the Diabetes Control & Prevention Program of the Michigan Department of Community Health.