1. Strategic dietary modifications to achieve target goals in Hypertension Geejo Geevarghese – M.D Cook County-Loyola-Provident Family Medicine Residency Program

2. Objectives To influence family physicians help patients achieve target goals by adapting a healthier dietary lifestyle To list 10 food alternatives to help control HTN To emphasize patient and family education on the types of foods hypertensive patients can eat or should avoid To construct DASH diet while also heightening awareness of sodium rich foods

3. Hypertension 50 million people in the U.S. and approximately 1 billion worldwide Most common cause of outpatient hospital visits

4. Hypertension Treatment Lifestyle Modifications to Prevent and Manage Hypertension 1. Maintain normal body weight for adults (BMI: 18.5-24.9 kg/m2) – (5-20 mmHg/10 kg) 2. Sodium intake: (previously approx. 2.4 g of sodium per day  1500mg sodium daily (AHA 2010 guidelines) – (2-8 mmHg) 3. Regular aerobic physical activity ( 30 minutes per day 5x week – (4-9 mmHg)

5. Hypertension Treatment 4. Limit alcohol consumption to no more than 30 mL of ethanol (e.g. 720 mL of beer, 300 mL of wine, or 60 mL of liquor) per day in most men and no more than 15 mL of ethanol per day in women and lighter weight persons - ( 2-4 mmHg) 5. Intake of dietary K+ (>90 mmol/d or 3,500 mg per day) – (2-4 mm Hg ) 6. Diet rich in fruits and vegetables ; low-fat dairy products with a reduced content of saturated and total fat (according to the DASH eating plan). (8-14 mmHg)

6. DASH DIET

7. DASH Diet Dietary Approaches to Stop Hypertension National Heart, Lung and Blood Institute (NIH), and AHA to control hypertension; USDA 11 week trial - multi-center, randomized, outpatient feeding study ; testing the effects of dietary patterns on blood pressure DASH randomly assigned 459 patients with BP < 160/80-95 mmHg to a 1. control diet low in fruits and vegetables VS. a diet rich in fruits and vegetables (2.8/1.1)VS. combination diet rich in fruits and vegetables and low-fat dairy products and low in saturated and total fat (11.4/5.5)

8. DASH Diet - 4-5 servings of fruit -4-5 servings of vegetables -2-3 servings of low-fat dairy -(all foods must contain less than 25 percent total fat per serving) Emphasized fruits and vegetables, low-fat dairy food, low in saturated fats, total fat, and cholesterol

10. DASH Diet Reduced SBP by 6mmHg and diastolic BP by 3mmHg = Normal pts HTN: dropped by 11 and 6, respectively DASH Sodium - 1500 mg - biggest blood pressure benefits were gained Evidence based guidelines - most clinicians agree that people with high blood pressure should consume < 2000 milligrams (2 grams) of sodium per day ( or 1500 to 1800 mg per day).

12. WOW! Americans consume on the average 4000 to 6000 mg of sodium a day 2000mg of sodium is equal to 1 teaspoon of salt –AVOID SALT! All our bodies actually need is 500 mg sodium or ¼ teaspoon.

14. Sodium Labelsn

15. Patient Education Read Nutrition Labels! – limit sodium intake Serving sizes Avoid foods with sodium in it (MSG, disodium phosphate, sodium benzoate, sodium hydroxide, sodium nitrite) Detailed food record and add up sodium intake. less packaged and processed (frozen meals, canned foods, pickled foods, snack foods, lunch meats, condiments, sauces, and dressings) foods Educate family

16. Patient Education: Eat less processed food (cans, boxes, jars & bags) Eat in restaurants less often Instead of buying pre-made, processed foods, buy fresh or fresh-frozen fruits and vegetables Buy meats, fish, chicken, and turkey that are fresh instead of canned or sold at the deli counter Make meals from scratch at home using these low-sodium ingredients

17. Patient Education Eating Out: Can meal be made without salt? Avoid foods that come with sauces or dips Choose plain grilled meats or fish and steamed vegetables Ask for oil and vinegar for salad, rather than dressing

18. Ways to cut down on Sodium Put away salt shaker /reduce salt/ GET RID OF IT! Experiment with fresh herbs, garlic, onions, lemon Spice blends without sodium ex: Mrs. DASH Citrus and flavored vinegar – tasty alternatives! Low sodium products: tomato products, and tuna

19. Ways to cut down on Sodium Avoid eating at fast food restaurants Dining out – request food prepared without salt Restaurants that offer fruits & vegetables; dressings or sauces on the side Avoid bacon bits, cheese, and croutons at the salad bar Do not add salt to food while cooking or before eating Teach family members to taste food before adding salt

20. Remember: Salt is an acquired taste; taste buds can be retrained in less than 2-3weeks, if patients stick with the lower sodium diet Implement DASH Diet!

21. Sodium Rich foods Canned soups Rice and noodle mixes Sauces, dressings, & condiments Pre-made frozen meals (“TV dinners”) Deli meats, hot dogs, & cheeses Smoked, cured, or pickled foods Restaurant meals, cafeteria meals

22. Foods to avoid Breads : - Biscuits - prepared mixes (pancake, muffin, corn bread) - instant hot cereals - many boxed cold cereals - self-rising flour Crackers and snack foods : - Salted crackers and snack items (chips, pretzels, popcorn) - regular peanut butter - prepared dips/spreads - salted nuts or seeds

23. Foods to avoid Pasta, rice, and potatoes : -Macaroni and cheese mix -rice, noodle, or spaghetti mixes -canned spaghetti -frozen lasagna -instant potatoes; -seasoned potato mixes Beans and peas: -Beans or peas prepared with ham, bacon, salt pork, or bacon grease -all canned beans

24. Foods to avoid Meats and proteins - Salted, smoked, canned, spiced, and cured meat, poultry or fish - bacon; ham; sausage; - lunch meats; - hot dogs - breaded frozen meat, fish, or poultry - frozen dinners - pizza

25. Fruits and vegetables -Regular canned vegetables and vegetable juices -olives, pickles, relishes, sauerkraut -frozen vegetables in butter or sauces -crystallized and glazed fruit -maraschino cherries -fruit dried with sodium sulfite Dairy products -Buttermilk -Dutch processed chocolate milk -processed cheese slices and spreads -cottage cheese, aged or natural cheese

26. Foods to avoid Fats and oils -Prepared salad dressings -bacon, salt pork, fat back -salted butter or margarine Soups -Regular canned or prepared soups, stews, broths, or bouillon -packaged and frozen soups Desserts - Packaged baked goods Beverages -Softened water -carbonated beverages with sodium or salt added - regular tomato juice (V-8) -ask about alcoholic beverages

27. Foods to avoid : Condiments - Table salt, lite salt -bouillon cubes -meat extract -taco seasoning, -Worcestershire sauce -tartar sauce -ketchup -chili sauce -cooking sherry and wine onion salt mustard garlic salt soy sauce tamari meat flavoring or tenderizer steak and barbecue sauce seasoned salt Dutch processed cocoa MSG

28. Foods to choose – Low Sodium Breads : -Whole grain breads - English muffins -Bagels - corn and flour tortillas - most muffins Cereals: -Many cooked low salt (read the label to determine sodium content) -hot cereals (not instant) such as oatmeal -cream of wheat - rice, or farina -puffed wheat, puffed rice -shredded wheat Crackers and snack foods: -All unsalted crackers and snack foods -unsalted peanut butter -unsalted nuts or seeds -unsalted popcorn Pasta, rice, and potatoes : -Any type of pasta (cooked in unsalted water) -Potatoes -white or brown rice

29. Foods to choose – Low Sodium Meats and protein: -Fresh or frozen beef, poultry, and fish -low sodium canned tuna and salmon - eggs or egg substitutes Fruits and vegetables : -Any fresh, frozen, or canned fruit -Any fresh or frozen vegetables without sauce -Canned vegetables without salt -low-salt tomato sauce/paste Dairy products : -Milk -Cream -sour cream -non-dairy creamer -Yogurt -low-sodium cottage cheese -low sodium cheese -ricotta and mozzarella cheese

30. Foods to choose – Low Sodium Fats and oils: -Plant oils (olive, canola, corn, peanut) -unsalted butter or margarine Soups : -Salt-free soups and low- sodium bouillon cubes, -unsalted broth -homemade soup without added salt Desserts : -Gelatin -Sherbet -Pudding -ice cream -salt-free baked goods -sugar, honey, jam, jelly, marmalade, syrup

31. Foods to choose – Low Sodium Beverages: -Coffee -Tea -soft drinks -fruit flavored drinks -low salt tomato juice any fruit juice Condiments: -Fresh and dried herbs (onions,garlic, basil,) -lemon juice -low-salt mustard -vinegar, -Tabasco sauce -low- or no-salt ketchup -seasoning blends that do not contain salt

32. Summary Implement DASH Diet to achieve target goals in hypertension Educate the patient and family – DASH Diet, sodium rich foods, low sodium foods, nutrition labels, help monitor sodium intake