This document discusses management of hypertension through lifestyle factors like nutrition and physical activity. It provides guidelines on dietary approaches such as limiting salt, alcohol and red meat intake while increasing consumption of fruits, vegetables, whole grains, fish and unsaturated fats. Regular physical activity of at least 30 minutes per day is recommended. Diets high in quality carbohydrates and plant proteins like the DASH diet have been shown to lower blood pressure and reduce cardiovascular risk.

1. Features of management of patients with AH
(nutritional status, physical activity)
Department of outpatient therapy, MD
Shulkina SG

2. 1/3
arterial hypertension - global problem

3. Dyslipidemia - a common risk factor for
cardiovascular disease

4. Metabolic complications obesity - global
problem

5. Achieving the goal in the treatment of
hypertension

6. hypertension management.
Low- and middle-income
countries
High-income country
years 2000 2010 Δ 2000-
2010
2000 2010 Δ 2000-
2010
Prevalence 23,8% 31.5% 7.7% 31,3% 28,5% -2.6%
Aware of the presence
of hypertension
32,3% 37,9% 5.6% 58,2% 67,0% 8.8%
receive treatment 24,9% 29% 4,1% 44,5% 55.6% 11,1%
succeed 8.4% 7.7% -0.7% 17,9% 28,4% 10,5%
Burent M., Brent ME Circulation Research. 2019; 124: 1124-1140
50% with hypertension under 40 y.o. stop therapy

7. Epidemiology of hypertension
in Russia: Evidence from a
study ESSAY-RF

8. Control of hypertension in Russia
Shalnova SA, et al Cardiovascular pathology and prophylaxis;. 2018; 12 (4)

10. stroke kidney failure
Uncontrolled hypertension and the risk of
cardiovascular events
• AG increases risk
development of
cardiac, cerebral and
renal pathology
• uncontrolled
hypertension It can lead
to cardiovascular
conditions. such as
stroke and myocardial
infarction
• Messerli FH, et al. Lancet. 2007; 370:
591-603.
myocardial infarction
AH
Asymptomatic
target organs defeat
Prehypertension state

11. Key information that should be collected from
patients and their relatives (continued)
• Anamnesis possible: secondary hypertension
• Start hypertension of 2-3 degrees at a young age (<40 years), or sudden onset of hypertension or a rapid deterioration of hypertension in
the elderly
• History of kidney disease or urinary tract disease
• Use of psychoactive drugs, corticosteroids, nasal vasoconstrictors, chemotherapy
• Repeated episodes of sweating, headache, anxiety, palpitations or suggestive of pheochromocytoma
• Anamnesis spontaneous or provoked hypokalemia-diuretic, muscle weakness and episodes of convulsions
• Symptoms suggestive of thyroid disease or hyperparathyroidism Pregnancy in the present or the past, and receiving oral contraceptives
History of sleep apnea
• Admission antihypertensive drugs
• Admission antihypertensive drugs, including efficiency and intolerance to previous treatment
• Adherence to therapy

12. Factors that influence the control of hypertension in Russia
Excessive alcohol consumption
increased heart rate
Low and medium level of education
Shalnova SA, et al Cardiovascular pathology and prophylaxis;. 2018; 12 (4)
start treatment

13. Factors that influence the control of
hypertension in Russia
increased heart rate
Low and medium level of education
hypertriglyceridemia
hyperglycemia
Obesity
Age
Achieving control
during treatment
Shalnova SA, et al Cardiovascular pathology and prophylaxis;. 2018; 12 (4)

14. The diagnostic criteria for hypertension according to the clinical and
ambulatory blood pressure measurements
European Heart Journal (2018) 00, 1-98. doi: 10.1093 / eurheartj / ehy339
BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure.
aRelates more to traditional measurement klinichesskogo blood pressure, not to measure without medical personnel
clinical blood pressurea
(Or office blood pressure)
Category SAD (mmHg). DBP (mmHg).
≥140 and / or ≥90
BP in an outpatient setting
Average daily blood pressure
(during wakefulness time)
≥135 and / or ≥85
Mean BP sets (sleep) ≥120 and / or ≥70
Mean daily blood pressure ≥130 and / or ≥80
The average home blood
pressure
≥135 and / or ≥85

15. Target values ​​clinical (office) BP
European Heart Journal (2018) 00, 1-98. doi: 10.1093 / eurheartj / ehy339
* - not applicable to patients with acute stroke
** - you can change the target levels of blood pressure in elderly debilitated patients
18-65 years
age
groups
The title DBP
(mm Hg
Article)
The title SBP (mm Hg. V.)
AG DM + CKD + CHD
+ Stroke /
TIA *
65-79 years **
≥ 80 years old **
Size office DBP (mm
Hg Article)
The purpose of 130
or lower at a
hypersensitive
Not <120
The purpose to 130
or lower when
intolerances
Not <120
goal to
<140 to
130 when
transferrin
g bridge
70-79
The goal to 130-139 with portability
Not <120
The goal to 130-139 with portability
70-79

16. The potential effect of reducing blood
pressure to reduction in mortality from
cardiovascular diseases
According to a meta-analysis 5 large population-based studies
Whelton PK, et al. JAMA. 2002; 288: 1882-1888.Stalmer R. Hypertension. 1991; 17 (Suppl 1): I16-I20
reductions in
SBP
reduction in mortality
CHD Stroke Overall
-2 mm. Hg. Art. -4% -6% -3%
-3 mm. Hg. Art. -5% -8% -4%
-5 mm. Hg. Art. -9% -14% -7%

17. Thresholds clinical HELL for initiation of therapy
aTherapy can be seen in these patients with very high risk for CAD and corresponding high normal blood pressure (SBP i.e. 130-140 mm Hg. V.)
Age group Thresholds clinical SBP, mm RTST
Thresholds
clinical DBP,
mm Hg Article
18-65 years
65-79 years
≥80 years
Thresholds
clinical DBP,
mm Hg Article
Arterial
hypertension + Diabetes + CKD + CHD
+ Stroke /
TIA
≥140
≥90
≥140
≥90 ≥90 ≥90 ≥90
≥140 ≥140a ≥140a ≥90
≥90
≥90
≥140 ≥140 ≥140 ≥140a ≥140a
≥160 ≥160 ≥160 ≥160 ≥160
European Heart Journal (2018) 00, 1-98. doi: 10.1093 / eurheartj / ehy339

18. The potential effect of reducing blood pressure to a reduction in mortality
from cardiovascular diseases
According to a meta-analysis 5 large population-based studies
Whelton PK, et al. JAMA. 2002; 288: 1882-1888.Stalmer R. Hypertension. 1991; 17 (Suppl 1): I16-I20
reductions in
SBP
reduction in mortality
CHD Stroke Overall
-2 mm. Hg. Art. -4% -6% -3%
-3 mm. Hg. Art. -5% -8% -4%
-5 mm. Hg. Art. -9% -14% -7%

19. Target values of blood pressure
All patients 18-65 years
120-130 / 70-80 mm Hg. Art.
• TIA / stroke
• CHD
• SD
> 65 years
CKD
130-140 / 70-80 mm Hg Article
120-129 / 70-79 mm Hg
for all patients under 65 y.o!!!
ESH / ESC 2018

20. Intervention for lifestyle changes in patients
with hypertension or high-normal blood
pressure
It is recommended to limit salt intake <5 g per day
It is recommended to limit alcohol consumption to:
• Less than 14 servings (ITC * per week for men
• Less than 8 servings (it1) * a week for women
Advised to avoid heavy drinking, binge-drinking
It is recommended to increase consumption of vegetables, fresh fruits, fish, nuts and unsaturated fatty
acids (olive oil), consumption of dairy products with low fat, reduced consumption of red meat
Shows body weight control, avoiding obesity (BMI> 30 kg / m2 or waist circumference> 102 cm in men
and> 88 cm for women) with a target level of healthy BMI (about 20-25 kg / cm2) and the waist
circumference (<94 cm for men and <80 cm for women) in order to reduce blood pressure and risk-SS

21. Intervention for lifestyle changes in patients
with hypertension or high-normal blood
pressure
Recommended regular aerobic exercise (eg, at least 30 minutes of moderate dynamic
loads 5-7 days a week).
It is also possible to perform power loads 2-3 times a week
Recommended cessation of smoking, the direction of the smoking cessation program

22. Trends in consumption of carbohydrates, fats and proteins in
the adult US population from 199 to 2016 GG (n = 43996)
1. Decreased consumption of "poor
quality" of carbohydrates (sugars)
2. Increased consumption of "high
quality" carbohydrates (whole
grain products), vegetable protein
(nuts) and polyunsaturated fats.
3. 42% of energy consumption was
still derived from the low-quality
carbohydrates and saturated fat
intake remained more than 10%.
JAMA The Journal of the American Medical Association 322 (12): 1178-1187
DOI: 10.1001 / jama.2019.13771

23. Federal Law of November 21, 2011 Federal Law number 323-
"On the basis of protection of health of citizens of the Russian
Federation"
Clinical nutrition is an integral component of the treatment
process of preventive measures and includes nutrition plans,
which have a chemical composition, energy value, consist of
certain products, including specialized clinical nutrition
products, subjected to an appropriate treatment.

24. WHO nutritional approaches
2007
• Limit energy intake from
total fats,
• Reduce your intake of
saturated fats, replacing
them with unsaturated
• Exclude reception trans
fatty acids
• Increase consumption of
fruits, vegetables, legumes,
whole grains and nuts
2016
to increase consumption
whole grain products,
vegetables, fruits,
legumes and nuts.
Reduce the consumption of
red meat and processed
meat products, sugary
drinks and juices, refined
grain products

25. Food based dietary patterns and chronic
disease prevention
BMJ. 2018; 361: k2396.

26. AHEI- alternative index of healthy food (2010)
The consumption of vegetables was associated with a lower risk of cardiovascular disease and some cancers. In
particular, green leafy vegetables may reduce the risk of diabetes.
One portion - 0.5 cups 1 cup vegetables or green leafy vegetables (1 cup = 236.59 g).
Consumption of fruit was associated with a lower risk of cardiovascular disease and some cancers.
One portion - 1 0.5 Average fruit or berries cups (one cup = 236.59 g).
Greater consumption of whole grains is associated with a lower risk of cardiovascular disease, diabetes and cancer. In
contrast, refined grains may increase the risk of diabetes, coronary heart disease (CHD) and other chronic
diseases.
One serving of 100% wholemealproduct (i.e., 0.5 oatmeal glass or brown rice) contains ~ 15-20 g whole grain (on
dry basis). We believed that the 75 g / day is optimal (~ 5 servings / day) for women and 90 g / day (~ 6
servings / day) - is optimal for men
Consumption of sugar-sweetened beverages, including carbonated and fruit drinks is associated with an increased
risk of weight gain and obesity, diabetes. We have included the consumption of fruit juices in this category, given
the positive association with diabetes risk and the lack of a positive influence on Cardiovascular disease or
cancer.
We thought ≥1 serving / dthe least optimal. One serving is 8 ounces (1 ounce = 28.35 g).

27. AHEI- alternative index of healthy food (2010)
Nuts, legumes and vegetable protein (e.g., tofu) Are important sources of protein and contain critical
components, such as unsaturated fats, fiber, copper, magnesium, vegetable sterolsand other nutrients.
Nuts and other plant proteins have been associated with a lower risk of cardiovascular disease, especially
when used as a replacement for other protein sources, such as red meat. Nuts are also associated with a
lower risk of developing diabetes and weight gain while their association with cancer has not been proven.
One portion - 1 oz (1 oz = 28.35 g) nuts or 1 tablespoon (15 ml) of vegetable oil.
Consumption of red meat and processed meat is associated with an increased risk of coronary heart disease,
especially when replacing nuts, poultry or fish. Red meat and / or processed meats are also associated with
a higher risk of stroke, diabetes andcolorectal and other cancers.
1 is considered less ideal batch / monthswith an upper limit ≥1,5 servings / day. One portion - 4 oz raw meat
or processed meat 1.5 oz (1 oz = 28.35 g).
One serving of fish per week, particularly types with a high content of long chain (n-3) EPA + DHA fatty acids,
provides reliable protection from fatal arrhythmias and sudden cardiac death and can reduce the frequency
of others.
Acronym for optimum consumption (250 mg / day) of 2- ~ 4-ounce servings of fish / week, which
corresponds to current recommendations (1 oz = 28.35 g).

28. Diet DASH
(Low salt)
Lowering blood pressure,
LDL-C, body weight (by
increasing physical activity)
Reducing the risk of CV
events by 20%
decrease CHD risk by 21%
and of stroke by 19% HF to
29%.

29. Reduction in total mortality
Reducing the incidence of CC
Reducing MI
Reduction in total mortality from cancer
decrease neurodegenerative diseases
Reduction type DM2

30. 2016 European Guidelines on cardiovascular disease prevention in
clinical practice
Nutrition: with low levels of saturated fat
emphasis on consumption
whole grain products
vegetables and fruits
and fish

31. 2019 ACC / AHA Guideline on the Primary Prevention of
Cardiovascular Disease
• Consumption of vegetables, fruits, nuts, Low-fat protein sources of
vegetable and animal origin, and fish (1)
• as well as a reduction. Consumption of trans fats, red meat and
processed red meat, refined carbohydrates and sugary drinks (2a)
• Replacing saturated fats to mono- and polyunsaturated It may be
useful for reducing the risk of the AU and the GCC (2a)
• A diet with a decrease in cholesterol and sodium can be helpful for
reducing the risk of AC and CC (2a)

32. MIND -diet + DASH - diet
MIND -diet- version of the
Mediterranean diet, aimed at
reducing the SAD, for the
prevention neurodegenerative
change
Accent the green leafy vegetables
and berries
less value- dairy products,
potatoes, fish

33. paradoxes of power
"French paradox" - high consumption of animal fats from dairy
products may be offset by the consumption of alcohol beverages
"Alpine paradox" adaptation of the Mediterranean diet under the
regional characteristics
"Nordic Diet" - a lot of local produce in compliance with the principle of
seasonality: The protective role of fish of the northern seas.

34. Daily consumption of animal products among those with
hypertension or without hypertension (ESSAY-RF)
52
9
25
52
13*
26
39
9
28
36*
12*
30
red meat fish chicken
Chart Title
м АГ- м АГ+ ж АГ- ж АГ+

35. Daily consumption of vegetables and confectionery among
hypertensive and normotensive (ESSAY-RF)
48 46
52*
40*
64
55
67*
46*
vegetables confectionery
Chart Title
м АГ- м АГ+ ж АГ- ж АГ+

36. Daily consumption of dairy products among those with
hypertension or without hypertension (ESSAY-RF)
44
21
14
36
44
20
15
35
53
20 19
44
54
21
24*
43
milk sour cream curd cheese
Chart Title
м АГ- м АГ+ ж АГ- ж АГ+

37. Daily consumption of staple among hypertensive and
normotensive (ESSAY-RF)
27
11
59
27
12
57
19
9
62
20
12*
60
sausages saltings excess salt in food
Chart Title
м АГ- м АГ+ ж АГ- ж АГ+

38. Daily consumption of staple among hypertensive and
normotensive (ESSAY-RF)
When the diagnosis of hypertension:
Received the differences on the level of consumption of dairy products,
cereals and legumes.
BUT!!!
Consumption of sausages, pickles and excess salt in food is not
changed !!!

39. priority lines nutritional medicine
1. Interaction with food microbiota
2. food interaction with drugs
3. Interactions with drugs probiotics
Example:
RAAS blockers
ACE inhibitors ( enalapril- increase bioavailability with fatty meals and
grapefruit juice)
APA

40. Physical activity is
• Any movement of the body produced by skeletal
muscles, which leads to energy consumption level
more than in rest.
• Activity during the day at work, home, sports, active
hobbies.

41. 3 physical activity level
1. low - 1.1 to 2.9 MW / m
2. average - 3-5,9 MET / min (total duration of
employment of at least 30 min /day = 150 kcal)
3. Intense and -6 > MET / min
Minimal physical activity - duration of one
class must be not less than 10 minutes!

42. Costs 500 MET / min per week
reduces the risk of premature
death !!!

43. Expenses > 500 MET / min per
week reduces the risk of
developing breast cancer !!!

44. For effect
• It is necessary to engage 150min / week (2 hours and 30
minutes) at a moderate aerobic exercise level or FA 75
minutes / week with vigorous level FA.
• For more efficiency (obesity) - 300 m / week (5 hours) - in
the form of aerobic exercise at a moderate level of FA, or
150 minutes / week with vigorous level FA.
Isometric load is contraindicated !!!

45. Control the intensity of your exercise
Maximum heart rate
reductions (MHR) for healthy
man "220-age"
• Moderate intensity -
55-70% MHR
• Much intensity -
70-85% of MHR

46. Need to know, toato build activity to improve
physical activity
Each wellness workout should consist of three phases
1. warm-up part classes.
The main purpose of the warm-up:
• a) heat the body,
• b) cause a gradual increase in heart rate
5-10 minutes
2. Main part - aerobic phase
• should be brought to the level of intensity of the load of 50% - 70%
of the maximum heart rate and age keep this intensity is not less
than 20 - 60 minutes per session.
3. Final part classes - phase out of aerobic exercise, very important
for adaptation of the organism. Its duration 20-30 minutes

47. Reductions in SBP by 10.8 mm Hg v., DBP 4.7 mm Hg Article - 40-60 min
≥3 P /weeks, 4 weeks
3.4 SBP mm Hg Article, Diastolic blood pressure of 2.7 mm Hg Article30-
60 minutes, 2 times a week 50-75% of max heart rate; 4 weeks
5.7 SBP mm Hg ArticleDBP 3 mm Hg Article- 3 sets of 8 exercises,
11 repetitions three times per week, 6-48 weeks
Integr Blood Press Control. 2018; 11: 65-71.
Published online 2018 Sep 20. doi: 10.2147 / IBPC.S136028

48. calculation of nutrients
1. normal weight
Carbohydrates 30-50%
Proteins 25-35%
Fats 25-35%
2. Overweight
carbohydrates 10-20%
proteins 40-50%
fats 30-40%
3. Reduced weight
carbohydrates 40-60%
proteins 25-35%
fats 10-15%
1 g of 4 kcal belka-
1 g of fat - 9 kcal
1 g carbohydrate -4 kcal

49. calculation of nutrients
Proteins- 30%
Fats -25%
Carbohydrates - 45%
1718 kcal = 0.3 x 515, 4 Kcal (protein)
Since 1 g of the protein energy content of 4 kkal- need 515.4 / 4 = 128 g protein.
1718 kcal x 0.25 = 429.5 kcal (fat)
Since 1 year fat energy value 9 kkal- need 429.5 / 9 = 47.8 g fat.
1718 kcal x 0.45 = 773, 1 kcal (Carbohydrates)
Since 1 year carbohydrates energy value 4 kkal- need 773.1 / 4 =193 g carbohydrates.

50. Calculate calories and diet for:
Task 1
A young man, 23 years old, wants to gain weight. Weight 70 kg, height
167 cm, average level of physical activity

51. Task 2
A Woman, 30 years old, wants to reduce weight. Height 165 cm, weight
90 kg. Metabolic parameters and blood pressure in the normal range.
Low levels of physical activity.
9.9.20

52. Task 3
A Woman 50 years old. He wants to reduce weight. Height 160 cm,
weight 100 kg, low physical activity level. BP 150/100 mm Hg. v., a
heart rate of 80 per minute. Metabolic parameters: glucose 6 mmol/
L, total cholesterol 6.0 mmol/ L, HDL 1 mmol/ L, LDL cholesterol 3.2
mmol/ L, TG 2.7 mmol/ L, ALT 37 U / L, AST 40 U / L, bilirubin 12 mol/
L creatinine 76 mol/ L, uric acid 200 mol/ L.
9.9.20