DASH Eating Plan: Preventing and Treating

Hypertension and More

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-IL-B2-02/02/17-2005

May 10, 2017 Telligen QIN-QIO

Facilitator

Kristen Marino, PCMH CCE Telligen QIN-QIO Sr. Quality Improvement Facilitator Kristen.marino@area-d.hcqis.org www.telligenqinqio.com

Presenter

Merle Shapera, MS, RD, CDE, LDN Telligen QIN-QIO Diabetes Program Specialist Merle.shapera@area-d.hcqis.org www.telligenqinqio.com

Polling Question

In your job, do you give information regarding blood pressure prevention or treatment DIRECTLY to health care

providers or beneficiaries and their families?

Yes No

Pre Test Questions

1) The current USDA recommendation for daily sodium is under 1500mg/day for people with high blood pressure.

True False

2) Which one of these DOES NOT help reduce blood pressure levels:

a. Sodium restriction

b. Potassium rich diet

c. Physical activity

d. None of the above, they all help reduce blood pressure

3) Senior males have higher blood pressures than senior females.

True False

Objectives of Presentation

• Upon completion of this presentation, participants will be able to:

• State two examples each of definition, causes, risk factors and diagnostic levels for hypertension

• Explain the research supporting the DASH Diet and its role in reducing high blood pressure

• Identify key components of the DASH Diet

What is Blood Pressure?

• The force of blood against the wall of the arteries

• Measured in mm Mercury (Hg)

• Written as systolic over diastolic 130/85

• Systolic – as the heart beats while pumping blood

• Diastolic – as the heart relaxes in between beats

• Systolic naturally increases as we age or get larger in size

• A chronic disease occurring when blood pressure (BP) is at a level that is at risk for complications.

• It increases chance for heart attack, stroke, kidney disease and visual impairment.

• A consistent BP of 140/90 mm Hg or higher is considered high BP.

• Hypertension has no warning signs or symptoms.

• Higher pressure makes the heart work harder to pump the blood.

• Higher pressure makes the arterial walls less elastic.

What is Hypertension?

Blood Pressure Stages

Category/Stage Blood Pressure Levels

Normal <120/80mmHg

At risk (prehypertension) 120–139/80-89mmHg

High >140/90mmHg

Stage 1 140–159 /90–99mmHg

Stage 2 160–179 /100–109mmHg

Stage 3 180 /110mmHg

Symptoms of Hypertension (HTN)

• Most people have NO symptoms

• It is a silent killer

• Symptoms of extremely high BP:

• Nosebleeds

• Headaches

• Shortness of breath

What causes High Blood Pressure?

• Although the exact cause is unknown, there are several possible causes:

• Narrowing of the arteries (atherosclerosis)

• Various medical conditions especially Diabetes

• Heart beating faster or more forcefully than it should

• Medications

Risk Factors for Hypertension

• Age

• Genetics/family history

• Race

• Weight

• Tobacco use

• Limited activity

• Too much sodium in diet

• Too little potassium in diet

Hypertension Prevalence

• Incidence in adults over 20

• Generally, 1 in 4 Americans

• 44% of African Americans vs. 33% of Caucasians and 28% Mexican Americans

• Lowest in Asian Americans and Pacific Islanders (<10%)

Seniors in US with Hypertension

65-74 Years 75 and older

Females 71% 80%

Males 64% 72%

• 75% are under current treatment

• 52% are controlled and 48% are not controlled

Source: NHLBI 2013

How Does HTN Affect the Brain?

• Number one risk factor for stroke

• Can cause a break in a weakened blood vessel which then bleeds in the brain

• Can also happen when a blood clot blocks one of the narrowed arteries in the brain

How Does HTN Affect The Heart?

• Major risk factor for heart attack

• Number one risk factor for Congestive Heart Failure:

• Blood moves more slowly through the heart

• Pressure in the heart increases

• Heart can’t pump enough oxygen and nutrients

• Heart chambers stretch to hold more blood

• Vessels become thick and stiff

• Fluid builds up in body

How Does HTN Affect The Kidneys?

• Kidneys act as filters to rid the body of waste

• High blood pressure can narrow and thicken the blood vessels in the kidney

• Waste then builds up in the blood resulting in kidney damage

• HTN is the second leading cause of ESRD (28%)

• Diabetes is the primary cause of ESRD (44%)

Data from Davita

How Does HTN Affect The Eyes?

• Can eventually cause blood vessels to narrow, thicken or break and leak blood into the eye

• Can result in blurred vision or even blindness

Preventing/Treating Hypertension: Research

• Trials of Hypertension Prevention Study (TOHP) 1997:

Weight management best prevention followed by

sodium reduction and exercise

https://www.ncbi.nlm.nih.gov/pubmed/17449506

http://health.mo.gov/data/interventionmica/HeartDiseaseandStroke/3406.pdf

Preventing/Treating Hypertension: Lifestyle

• Eat less sodium: How much is okay?

CDC Flyer Link

• Maintain a healthy weight (BMI)

Link to BMI Chart

• Physical activity

• Limit alcohol

• Quit smoking

Maintain Healthy Weight

• Blood pressure rises as weight rises

• 5-10% weight loss can significantly reduce blood pressure and blood sugar and LDL levels

• Maintain a BMI of <27 (See link for BMI table)

22-25 Underweight

25-27 Normal weight

27-29 Overweight

30 + Obese

Be Physically Active

• 30 minutes of moderate activity 5 days/wk (three 10 minute sessions or two 15 minutes sessions are okay)

• Use stairs instead of elevator

• Get off train/bus 2 stops early

• Park your car at the far end of the lot

• Walk to the store instead of drive

• Walk the dog – don’t let him/her do it in yard only!

• Stand up for 5 minutes every hour you sit

• Walk in place or do stretches at each TV commercial

Limit Alcohol Intake

• Alcohol may raise blood pressure: Ask your doctor

• What counts as a drink?

12 oz beer

5 oz of wine

1.5 oz of gin, vodka, scotch, whiskey

• Limit alcohol • No more thank 1 drink a day

• Red wine – better choice

Quit Smoking

• Injures blood vessel walls

• Speeds up process of hardening of the arteries

• After quitting, risk of MI drops significantly after one year

DASH Diet

Dietary Approaches to Stop Hypertension

• Evidence-based

• Increased servings of fruits and veggies

• 4-5 servings of nuts, seeds, and legumes (peas/beans) each week

• Daily low fat milk products

• Rich in potassium, magnesium, calcium, and fiber

DASH Diet Research

NIH DASH Diet Studies 1992-1997 https://clinicaltrials.gov/search/open/intervention=DASH+Diet

NIH DASH-Sodium trial 1997-1999 https://www.nhlbi.nih.gov/news/press-releases/2001/nhlbi-study-finds-dash-diet-and-reduced-sodium-lowers-blood-pressure-for-all

OmniHeart (Optimal Macronutrient Intake Trial for Heart Health) 2005 Harvard https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236092/

Mediterranean Diet http://www.naturalmedicinejournal.com/journal/2010-11/mediterranean-diet-and-mortality-second-meta-analysis

Benefits of Dash Diet

• Reduces risk of heart attack, stroke and CHF

• Reduces risk of kidney disease

• Strengthens bones and reduces risk of osteoporosis

• Reduces obesity

• Reduces the risk of some cancers

• Reduces risk of multiple chronic diseases including diabetes, pre-diabetes and hypertension

• May reduce risk of cognitive impairment with age

Sample Dash Diet

Whole Grains 7

Fruits 4

Vegetables 4

Low fat or non fat dairy foods 2

Lean meats, fish, poultry 2 or less

Nuts, seeds, and legumes 4

Fats and sweets limited

Type of Food Servings on

1600 calories/day Average Calories per Serving (Size)

Total Daily Calories (1600)

Whole Grains 5 80 per slice or 1/3c, – ½ c. 400

Fruits 4 1 small piece or ½ c. -1 1/4 c. depending on type

240

Vegetables 4 25 per cup raw or ½ c. cooked 100

Beans and Peas (Legumes)

1 80 per ½ c cooked 80

Nuts and Seeds 1-2 45 per 2 T. seeds or 4-10 nuts depending on nut

90

Lean Poultry, Fish, and other Protein

2 (3-4oz each) 30-50 per ounce of lean protein

350

Low Fat Milk/Yogurt 2 (8oz each) 100 per 1 c. 200

Fats and Sweets Limited 140

Table of Food Group Examples

Food Group Examples

Whole Grains 100% whole grain breads, crackers, brown rice, whole wheat pasta, bulgur, kamut, spelt, wheat barley, buckwheat, amaranth, oatmeal

Fruits Blueberries, strawberries, canteloupe, guava

Vegetables All water-based: excludes corn, peas, potatoes

Beans and Peas (Legumes) Lentils, split peas, black eyed peas, black/red/pinto/kidney beans

Nuts and Seeds Almonds, walnuts, pecans, cashews; pumpkin, sunflower, chia, hemp, flax

Lean Poultry, Fish, and other Protein Fish, chicken, turkey, pork tenderloin and chops

Low Fat Dairy Skim or 1% or any calcium fortified almond or coconut milk or low fat or skim yogurt or cheese

Fats and Sweets Butter, Oil, Cake, Cookies, Pie, Doughnuts

1600 Calorie Diet Sample Day

BREAKFAST -- 8am 1 cup oatmeal 1 cup blueberries 1 cup fat-free milk

DINNER -- 6:30pm 1 baked chicken breast (4 oz) 1 c. brown rice 1 c. steamed green beans Romaine lettuce w/tomato, cucumber, and garbanzo beans w/ 2 T. low-fat ranch dressing Iced tea w/lemon

LUNCH -- 1pm 1 turkey sandwich w/2 sl whole wheat 1 t. mustard and 1 T. low-fat mayo 2 oz turkey tomato and lettuce 1 c baby carrots 1 c. fresh pineapple 1 cup fat-free milk

SNACKS Morning 10:30am 1 c. low-fat plain Greek yogurt w/ ½ banana & 8 large strawberries Afternoon 3:30pm 4-6 whole grain crackers with hummus and red pepper slices Evening 9pm 1 medium apple and 1 low-fat string cheese

Facts about Sodium

• Sodium is 40% of salt, the other 60% is Chloride

• One teaspoon salt = 2300mg sodium

• 75% of U.S. sodium consumption is processed, prepackaged and restaurant foods

• 25% is from the salt shaker

• Eat less of: Processed meats, cheese

Seasoned packaged and frozen foods

Canned soup, vegetables

The Nutrition Facts Label

Old Label New Label

Low Sodium Label Terms

* Low is most recommended

**At least 25% or 50% less sodium per serving than the usual sodium level

American Heart Association Website

FREE (per serving)

Very Low (per serving)

LOW* (per serving)

REDUCED** LIGHT**

Calories <5 cals/serving < 25 cals <40 cals 25% less* 50% less*

Fat <0.5 g/serving < 1 g <3.0 g 25% less* 50% less*

Sodium <5 mg/serving < 35 mg <140 mg 25% less* 50% less*

Sugar <0.5 g/serving Not Defined 25% less* 50% less*

DASH in the News

• US News & World Report: January 5, 2017

• DASH Diet Ranked Best Diet for 7th year in row

• Chicago Tribune Health: January 10, 2017

• Research being done on Alzheimer’s Prevention using a combination of the DASH diet and the Mediterranean diet: too early for results

• The Washington Post: February 24, 2015

• DASH diet the first recommendation for lifestyle change

Dash in the News

• Google Top Diet Search List: December 16, 2014

• DASH Diet enters the list at #5.

• A healthy eating plan breaking through the diet clutter

• New England Journal of Medicine: August 14, 2014

"High-quality diets rich in potassium might achieve greater health benefits, including blood-pressure reduction, than aggressive sodium reduction alone."

The Mind Diet: Alzheimers’ Prevention Top Foods To Eat

• Dark Leafy Greens: Greens, Spinach, Kale, Swiss Chard

• Vegetables of all kinds

• Nuts of all kinds

• Beans of all kinds

• Blueberries

• Salmon

• Olive Oil

• Have one glass of red wine each day

• Limit butter, margarine, sugar, red meat

DASH Diet is Highly Recommended

• Million Hearts: Target BP

• The National Heart, Lung, and Blood Institute (NIH)

• The American Heart Association

• American Diabetes Association

• US Guidelines for Treatment of High BP

• Academy of Nutrition and Dietetics

DASH Information Resources

Books:

• The DASH Diet Younger You (prevent aging)

• The DASH Diet Weight Loss Solution

• The Everyday DASH Diet Cookbook

• The DASH Diet Action Plan (weight loss)

Website:

• www.dashdiet.org

• https://catalog.nhlbi.nih.gov/catalog/term/DASH-Diet

Conclusions

The DASH Diet is an effective, nutritionally well balanced and easily-utilized tool

approved by leading health organizations to help prevent

and treat not only hypertension, but many other chronic

conditions.

39

Willowbrook Family Practice – Dr. Uma Taparia

• Why the DASH Diet

• Healthy eating plan

• Easy to follow for patients

• Heart Healthy – especially for patients with hypertension, heart disease, diabetes and obesity.

• Implemented DASH Diet for her at risk patients including:

• Obesity

• Hyperlipidemia

• Diabetes

• Preventive care

Example of Implementation at Practice

Example of Implementation at Practice

• Outcomes for practice

• Quality data measures improved – HTN Control & BP Screening and F/U

• Increased opportunity for patient education and self-management

• Included in patient care plan and shared decision making

• Utilized as a quality improvement activity in addition to meeting module for Boards. Recommends to other Physicians

• Outcomes for patients

• Weight loss

• Improved blood pressure, lower cholesterol levels

• Feel better, healthier

• Increase awareness and knowledge.

• Tools and resources provided.

Some obstacles including: Patients who like to eat out, difficult to change habits.