Hypertension: how is it treated nutritionally?;

Our cardiovascular system is a closed circulatory network, where the heart plays the role of the central pump, while the arteries and veins are the conduits for the distribution and return of blood.

The main purpose of the cardiovascular system is to supply the body with sufficient amounts of blood for its metabolic needs both at rest and during exertion. To accomplish this purpose, it is necessary that the pressure in the arterial network is kept relatively constant at a certain level.

When blood circulates in the cardiovascular system, the walls of the blood vessels are put under pressure by the volume of blood flowing through them. In addition, a number of mechanisms regulate this pressure so that it is maintained at normal, as determined and defined, levels.

What are the limits of blood pressure?;

The measurement of the pressure in an arterial segment continuously follows cyclical changes, based on the phases of cardiac function. The characteristic values of such a cyclic variation are:

• The maximum or systolic pressure: Corresponds to the systolic phase of the heart and is influenced by the speed and force of cardiac contraction, aortic elasticity, ejected blood volume and arterial capacity.
• The minimum or diastolic pressure: Corresponds to the diastolic phase of cardiac function.
• The average pressure: Its value is slightly less than the half-sum of the average values of systolic and diastolic pressure.
• Differential pressure or pulse pressure: Corresponds to the difference between maximum and minimum pressure values.

In the following table you can see revised guidelines for systolic and diastolic pressure values (SBP, BP) that define hypertension:

Does the AP measurement represent the actual pressure?;

However, the BP measurement may not represent the patient's actual pressure in a significant number of cases.

A large number of patients, for example, manifest the white shirt phenomenon in the doctor's office, i.e. these patients, for psychological or neurological reasons, when they are in the doctor's office their blood pressure increases, leading the doctor to diagnose hypertension without necessarily having it.

Furthermore, these patients seemingly do not respond to treatment because each time they go to the clinic they will experience the same phenomenon and will be considered to have resistant hypertension.

The best way to investigate these patients is 24-hour recording of the patient's blood pressure in their home environment. This avoids giving treatment to patients who do not need it and also identifies those patients who are most at risk and who need more aggressive treatment.

What is the clinical picture of arterial hypertension?;

Arterial hypertension is an insidious chronic disease, for the reason that, as mentioned above, it is usually an asymptomatic disease and does not manifest obvious clinical symptoms, so that it is only noticed after an accidental diagnosis or when it is already in an advanced stage and the body begins to show serious damage to various organs.

Common symptoms of hypertensive patients are:

• The headaches
• The easy fatigue
• The pulse feeling
• Lack of mental concentration

These symptoms alone clearly do not imply the existence of hypertension. Suspicious findings in the retina or optic nerve are of great diagnostic value. The most serious consequential damage due to hypertension is due to complications in the heart, kidneys and brain.

Complications of blood pressure

Heart and blood pressure

The heart is likely to develop left ventricular hypertrophy, arrhythmias, atrial fibrillation and heart failure. If atherosclerosis is present, symptoms of aortic or coronary insufficiency may also occur; and myocardial infarction.

Blood pressure and kidney function

The kidneys can also be affected by arterial hypertension, but the damage and its severity depends on the form of hypertension (benign or malignant).

Among the relatively common renal symptoms are:

• The albuminuria
• Finding cylinders and white blood cells in the urine
• The polyuria
• The inability of the kidneys to concentrate urine

Brain complications due to hypertension

Cerebral complications occur in about 25% of hypertensive patients and are usually cerebral or subarachnoid haemorrhage and thrombosis from ischaemia.

What is the prevalence of hypertension?;

Worldwide, it is estimated that there are about 1 billion people suffering from hypertension.

In people aged 50 years and over, it is estimated that 1 in 3 people have a blood pressure equal to or higher than 160/95 mmHg.

Due to the fact that hypertension is often an asymptomatic disease, its diagnosis in the majority of cases is made by chance and statistical studies show that only 1 in 3 people suffering from hypertension are aware of their condition.

The WHO suggests that hypertension is the most prevalent condition worldwide and is on the rise, affecting every age and social class, making it a modern-day scourge.

It should also be emphasized that statistically, the average life expectancy for a person with normal BP is 6 years longer than that of a person with a BP of 140/95 and 10 years longer than that of a person with a BP of 150/100 mmHg.

What about hypertension in children?;

It should not be overlooked that today the upward trend in the frequency of diagnosis of hypertension in children is particularly worrying.

Previously, the proportion of children up to 18 years of age with high blood pressure was 1%, whereas today it is 4.5%. Among overweight/obese children, the percentage of those with high blood pressure unfortunately climbs to 11%.

Does smoking aggravate hypertension?;

For a smoker who has hypertension, the risk of developing coronary heart disease is 8 times greater than a healthy, non-smoking person.

What are the causes of idiopathic hypertension?;

The most common causes of hypertension are:

• Idiopathic hypertension (so characterized any case of hypertension whose etiology is not identified, covers about 80% of all cases of hypertensive patients and the most important of the factors implicated in its diagnosis is heredity)
• The arteriosclerosis
• The kidney diseases
• Mechanical urinary tract obstructions and adrenal tumours
• Hyperthyroidism
• An increase in intracranial pressure (due to hematoma, tumor, etc.)
• Aortic causes (stenosis, insufficiency, etc.)
• Tumours of the pituitary gland
• The idiopathic polyerythrhythmia
• Drugs or poisons (adrenaline, noradrenaline, ephedrine, corticosteroids, etc.)
• The toxaemia of pregnancy
• The dietary causes

What factors affect the prognosis of hypertension?;

Still, some factors that affect the prognosis of hypertension, that is, they are the risk factors for its manifestation as they are:

• Men older than 55 years old, women older than 65 years old
• Smoking
• Reduced physical activity and sedentary lifestyle
• Dyslipidemia (total Cholesterol >250 mg/dl, LDL-Cholesterol >155 mg/dl, HDL-Cholesterol: in men <40, in women <48 mg/dl)
• Family history of early cardiovascular disease
• The abdominal obesity
• C-reactive protein (CRP = or > 1 mg/dl)
• Diabetes mellitus
• Damage to one or more target organs (left ventricular hypertrophy, arterial wall thickening or atherosclerotic plaque
• Increased serum creatinine - in men: 1.3-1.5, in women: 1.2-1.4 mg/dl
• Microalbuminuria

How is hypertension treated?;

The final decision on which patients should start antihypertensive treatment belongs exclusively to the treating physician, who makes his decision based on 2 criteria:

1. The overall level of cardiovascular risk

It is calculated from biochemical testing (total cholesterol, HDL, LDL, triglycerides, sugar, creatinine, uric acid, potassium, calcium), and on data provided by tests involving hematocrit, urinalysis, electrocardiogram and

2. The level of systolic and diastolic blood pressure

The main objectives of each antihypertensive treatment are also based on the individual history of each patient, however, the intersection points of each treatment are: the achievement of the maximum reduction of the overall cardiovascular risk, the treatment of all modifiable risk factors and diseases associated with hypertension and finally, the reduction of systolic and diastolic BP levels as set by the health care provider.

What lifestyle changes are recommended?;

In any case where intervention is necessary, it consists of lifestyle changes and medication. By lifestyle changes we mean:

• Stopping smoking
• Reducing body weight
• Reducing excessive alcohol intake
• Increasing physical and physical activity
• The necessary arbitral amendments, which we will discuss at length below

The applied medication is started gradually or directly, depending on the health care professional's judgement, and is administered in fixed doses of an active substance or a combination of several active substances.

Stop smoking and hypertension

Smoking is one of the most common major causes of hypertension. Even a single cigarette is enough to cause a temporary increase in blood pressure, which returns to normal levels after about 30-60 minutes.

When the researchers measured blood pressure while the subjects were smoking, they found that within five minutes of lighting a cigarette, the subject's systolic blood pressure rose dramatically - more than 20 mmHg on average - only to gradually return to its original levels over the next 30 minutes. This means that the typical smoker's blood pressure increases significantly during the day.

Like people with unstable hypertension (in which pressure often rises in response to the stresses of daily life), smokers with pressure that falls into the pre-hypertension category may actually have stage 1 hypertension every time they light a cigarette.

For a smoker who has hypertension, the risk of coronary heart disease is 8 times greater than a healthy non-smoker. Of the thousands of chemicals in cigarette smoke, nicotine and carbon monoxide are the ones implicated in cardiovascular damage.

Weight reduction and blood pressure

Hypertensives who weigh more than 10% above their ideal weight may be able to lower their blood pressure just by losing weight. Losing the extra pounds facilitates the smooth functioning of the heart.

It is a fact that a large accumulation of fat, especially on the trunk (central obesity), increases the chances of arteriosclerosis and cardiovascular problems, a risk that is greatly reduced when weight is returned to normal.

Obesity negatively affects our heart in many ways and just one of them is that it predisposes to hypertension.

Reducing alcohol intake and heart health

Excessive alcohol consumption - three or more drinks per day - accounts for about 7% of cases of hypertension. Moderate consumption of mostly red wine has positive effects on the heart and reducing high blood pressure, due to certain antioxidants it contains, such as flavonoids.

Also, the resveratrol contained in wine reduces platelet aggregation, reducing the risk of blood clots and therefore heart attacks. However, high alcohol consumption increases the risk of A.I. Experts recommend that alcohol consumption should not exceed 1-2 glasses of wine per day.

Increasing physical and physical activity

The American College of Sports Medicine reviewed 4 studies on the effect of exercise on blood pressure. With regular aerobic exercise, participants experienced a reduction in their systolic and diastolic blood pressure by an average of 11 and 9 mmHg, respectively.

Although many studies have focused on high-intensity exercises such as running, several researchers have evaluated the impact of moderate activities such as walking. It appears that moderate-intensity exercise provided the same or even better results in terms of lowering blood pressure.

Regular physical exercise improves metabolism, stimulates the cardiovascular system, expands the strength of our heart and helps prevent hypertension. The exercise that benefits the cardiovascular system the most is aerobic exercise, such as walking, running, cycling, swimming, basketball, football, tennis and dancing.

Regular regular aerobic exercise reduces systolic and diastolic blood pressure, even in people who were previously completely sedentary. The benefits of exercise are significant even in sufferers (e.g. patients with diabetes, coronary artery disease, etc.), as long as it is properly planned by specialists.

DASH diet against hypertension

A large body of scientific research suggests that a reduction in salt intake, combined with certain other controlled dietary interventions, causes a significant reduction in both systolic and diastolic blood pressure.

This effect is even more pronounced in hypertensives, diabetics, the obese and the elderly. The combination of a sodium restriction diet and a DASH (Dietary Approaches to Stop Hypertension) diet has been shown to effectively reduce blood pressure in hypertensive patients.

The DASH diet is a dietary model where fruit and vegetable intake is highly increased, dairy products allowed for consumption are of zero or reduced fat content (0 or 1% fat), total and saturated fat intake is controlled and alcohol is not allowed. Also this dietary model provides increased amounts of potassium and calcium.

What is the timing of the DASH diet?;

In most epidemiological studies where the DASH diet has been implemented, the implementation time was 3 to 4 weeks, the caloric intake was around 2000 kcal/24h and sodium intake ranged from 50-150 mmol/dl. It has been documented that the DASH diet has a diuretic effect and this is perhaps one of the most important factors for its ability to lower blood pressure in hypertensive patients.

Where else does the DASH diet have positive effects?;

In addition to its use in hypertensive patients, the DASH diet has been shown to have other beneficial effects on certain deadly diseases, such as cardiovascular disease, stroke, osteoporosis and cancer.

What other dietary factors affect pressure?;

The dietary factors that are thought to affect blood pressure are numerous and act in many different ways. Some alter renal salt and water excretion (sodium, potassium, proteins), others affect ion exchange between arteriolar smooth muscle fibres (chloride, calcium, magnesium), others affect the balance of hormones that control salt and water excretion and smooth muscle fibre contraction (e.g. calories, linoleic acid).

Hypothermic diet

In general, a calorie-restriction diet (hypocaloric) for overweight hypertensive patients and a sodium-restriction diet are often taken as the primary means of treatment in terms of dietary intervention. It is important, however, that the patient should always start a dietary programme with the advice and guidance of a specialist.

Treatment with diuretics

In addition, when medication with diuretics coexists, due to the fact that a lot of potassium is lost in the urine, it is imperative to implement a diet with sufficient amounts of potassium.

Limitation of sodium

Almost 50% of people who have hypertension are salt-sensitive, which means that taking in large amounts of sodium greatly increases their blood pressure and puts them at risk of complications.

The sodium restriction diet is a normal diet in all respects, but where the dietician has taken care to limit the amount of sodium to be consumed. The usefulness of this diet lies in preventing incidents of hypertension, as well as the development of edema.

It is estimated that the average adult consumes about 10 g of salt, instead of the 4 g recommended by international organisations for healthy adults.

Where is sodium found?;

It has been estimated that 85% of the salt we consume is contained in convenience foods, while table salt accounts for only 15% of all the salt we consume.

1. Sodium is found as an ingredient in many foods, in water and in various medications and for this reason, it is extremely difficult to design a diet that is completely sodium-free.
2. Foods that contain significant amounts of sodium are meat, fish, poultry and dairy products.
3. The water still, as mentioned above, contains sodium in varying amounts, depending on the water supply. Only distilled water has no sodium, as all its minerals have been removed.

Food labels and blood pressure

Most food labels indicate whether or not foods contain sodium, as well as their sodium content. However, sodium can be present in other chemical forms than the familiar salt, which can be confusing for consumers.

Sodium chloride

Common salt is used in table salt, cooking, food processing, canning, etc.

Glutamate Monosodium Glutamate

A condiment used at home, in restaurants and in many packaged foods (canned, frozen, etc.).

Baking Powder

Used to accelerate the rising of bread and cakes.

Sodium bicarbonate

Common baking soda is used in the preparation of bread, bakery products and sweets.

Almi

It is used in food processing to prevent the growth of bacteria and is contained in canned food, frozen food, pickles, etc.

Disodium Phosphate Salt

Contained in industrial cheeses.

Sodium alginate

It is added to chocolate milks and ice creams to soften their texture.

Sodium benzoate

It is used as a preservative in various preparations (mayonnaise, dressings, etc.).

Sodium hydroxide

Sodium caustic soda is used in food processing to soften the skin of olives, corn, etc.

Sodium propionate

It is used for pasteurising cheeses and certain baked goods and cakes to prevent mould growth.

Sodium sulphite

It is used to bleach certain fruits that need artificial colouring (maraschino cherries, fruit glaze, etc.) and as a preservative for some dry fruits (e.g. plums).

What does the amount of sodium depend on?;

The amount of sodium intake allowed to the patient depends on the patient's condition and is determined by the health scientist. In exceptional cases, a strict diet with a sodium content of 0.25-0.50 gr/24h is given. A mild average restriction is the allowable amount of 1gr/24h of sodium.

Which foods are rich in sodium?;

Foods that are not recommended and are rich in sodium are:

• The packaged tomato & vegetable juices
• The canned fruit
• The canned vegetables
• The pickles
• Frozen vegetables with salt
• Smoked or canned meat and fish
• The salted butter
• The shrimp, the chips
• The salted nuts
• The soups in powder or can
• The ham
• The salted meats
• The ham
• The industrially prepared meals
• The baking soda
• The baking-powder
• The soy sauce
• The complete dairy products

What foods are recommended in hypertension?;

Foods suggested are:

• The fresh fruit
• The dry beans
• The skimmed milk
• Wholegrain breakfast cereals
• The coarsely ground wheat
• The pasta
• The rice
• Fresh fish and meat
• The olive oil
• The vinegar
• Seasonings without salt & lemon juice
• The unsalted nuts
• The honey
• The jam
• The jellyfish
• The candies

Potassium enrichment and hypertension

Epidemiological studies show an inverse relationship between blood pressure levels and dietary potassium intake. Almost all studies conducted in this area indicate that potassium supplementation achieves a significant reduction in both systolic and diastolic blood pressure.

A 12-year study showed that people who consumed low levels of potassium were 2.6 times more likely to die from a stroke. This effect, like that of the sodium mentioned earlier, is better documented for hypertensive patients.

By what mechanism does potassium affect health?;

Potassium is likely to affect the regulation of blood pressure through its ability to remove sodium from the body through diuresis or through its possible effect on vascular smooth muscle cells.

What drugs are used for hypertension?;

One class of drugs that hypertensive patients often use are diuretics. These drugs serve to remove sodium from the kidneys, but they also remove potassium at the same time. As a result, a hypertensive patient who follows long-term treatment with diuretic drugs is at risk of developing hypokalemia.

Hypokalemia is the disease caused by a low potassium content in the blood and one of its dangerous symptoms is that it can cause heart rhythm disturbances. For this reason, hypertensive patients taking diuretics should be informed on how to enrich their diet with potassium or, where the attending physician deems it necessary, be prescribed potassium supplementation.

Sources of potassium in our diet

Foods rich in potassium are:

• Cooked meat or fish
• Dairy products: milk, yoghurt
• Fruits: peaches, apricots, pears, bananas, dates, oranges, avocados, avocados, cantaloupe, figs, grapes, grapefruit, grapefruit, kiwi, pineapple, plums, strawberries, tangerine, watermelon
• Vegetables: beets, carrots, asparagus, broccoli, cabbage, fresh green beans, pumpkin, courgettes, zucchini, tomatoes, spinach, celery, potatoes, sweet potatoes,
• Beans
• Raisins
• Peanuts
• Walnuts

Calcium - Magnesium and hypertension

There are some scientific studies in which low calcium and low magnesium diets were applied to experimental animals and caused hypertension. Other studies have linked hard drinking water (high in calcium and magnesium) with the prevention of coronary heart disease and hypertension.

There are also a small number of epidemiological studies showing that calcium and magnesium supplementation reduces blood pressure in some patients. In any case, calcium and magnesium supplementation has not been scientifically documented to exert any significant effect, in terms of lowering blood pressure, in people with adequate dietary intake of these elements.

Lead and blood pressure

A large epidemiological study examined the relationship that blood lead levels may have with blood pressure. A total of 2165 women aged 40-59 years, who were at or after menopause, were examined.

The results of the studies showed that during and after menopause, the decrease in bone mass is accompanied by an increase in blood lead levels. Women who had the highest lead levels were also 40% more likely to have hypertension.

The study also showed that women with blood lead levels between 4.0 - 31.1 mgr/dl were more likely to have high systolic and/or diastolic blood pressure. This relationship was strongest in post-menopausal women.

Caffeine

Recent studies show that coffee consumption has a neutral effect on people with hypertension. Each recommendation, however, is individualised because everyone has their own unique medical history and with this in mind it is always best to consult your doctor. When calculating the amount of caffeine you consume in a day remember to take into account all caffeinated drinks/foods that contain it, such as coffee, chocolate drink, chocolate, cola drinks and tea.

Frying oils

It is well known that oils and fats in general are directly related to our cardiovascular system and our health in general. Dieticians and doctors repeatedly emphasise the uniqueness of virgin olive oil in terms of the benefits of its exclusive use in our kitchen, raw or in cooking.

Its beneficial effect lies in the excellent ratio of saturated and unsaturated fatty acids in its composition (this composition is approximately - depending on the quality - 15% saturated, 75% polyunsaturated and 10% monounsaturated fatty acids).

However, it is common to use various other oils, mainly for frying food. When cooking the oil, heating it alters many of its characteristics and leads to the release of certain substances, which we eventually consume. In particular, oils that are fried over and over again several times acquire a very high content of polymers and polar compounds.

These compounds accumulate over time in our body and it is likely that at some point they will act cumulatively, manifesting some negative effect on our health. Scientific studies suggest that people with high levels of such polymers and polar compounds in their blood have an increased chance of developing hypertension.

It should also be noted that in people who also use olive oil for frying, these substances are found in their blood in much lower concentrations, since the same oil is not reused more than 2-3 times.

Therapeutic strategy against hypertension with drugs

When arterial hypertension does not subside despite the diet and the necessary changes in the person's lifestyle, then it may be necessary to proceed with treatment by starting antihypertensive treatment with medication, under the clear instructions of the attending physician.

The start of treatment, except in cases of extreme severity, is gradual, as is the gradual achievement of target blood pressure. In order to achieve this target blood pressure, a combination therapy is usually required. Treatment may be initiated with a low dose of one active substance or with a combination of low doses of two active substances.

Starting treatment with two drugs

The traditional view that antihypertensive therapy should be started with one drug was questioned in the 2003 guideline recommendations for the treatment of hypertension. According to the American National Commission on Hypertension, initiation of two-drug therapy is recommended in people with hypertension greater than 160/100 mmHg, and in people with blood pressure values 20/10 mmHg above target.

The European Society of Hypertension-European Society of Cardiology also suggests starting treatment with two drugs in selected cases, depending on the level of blood pressure and overall risk.

Myocardial infarction and heart failure

There is complete agreement between the new guidelines on the preferential use of diuretics in the elderly, beta-blockers and ACE inhibitors after myocardial infarction and in heart failure (ACE inhibitors and left ventricular dysfunction), and ACE inhibitors and angiotensin antagonists in chronic renal failure.

Diabetic nephropathy

The European Society of Hypertension-European Society of Cardiology and the World Health Organization-International Society of Hypertension recommend ACE inhibitors in type-1 and angiotensin antagonists in type-2 as the first choice in diabetic nephropathy.

Less binding is the position of the American National Commission on Hypertension, which recommends the use of ACE inhibitors or angiotensin antagonists in renal impairment, regardless of the type of diabetes. However, none of the guidelines state a specific preference for any class of drugs for diabetic individuals with normal renal function.

Hypertrophy of the left ventricle

In left ventricular hypertrophy, the European Society of Hypertension-European Society of Cardiology and the World Health Organization-International Society of Hypertension support the preference for angiotensin antagonists.

Stroke

Finally, in a history of stroke, the American National Commission on Hypertension and the World Health Organization-International Society of Hypertension recommend diuretics and ACE inhibitors as first-line treatment.

Effects of antihypertensive drugs

Finally, some reliable scientific research on antihypertensive drugs indicates a number of other effects that can be taken into account in individual cases.

Such effects include, for example, the suspicion that certain active substances used in some antihypertensive drugs have the potential to reduce the formation of chemical compounds in the body that cause ageing and damage to the kidneys.

Evangelia Panagiotopoulou, dietician / nutritionist & Antonis Alaveras, chief pathologist, 1st Pathology Clinic, EES Hospital