Goals of Therapy for Hypertension and Diabetes Mellitus in the Primary Healthcare Setting.

1. GLUCOSE & BP GOALS OF
THERAPY - LIFESTYLE
MODIFICATIONS IN NCDS:
A PATIENT CENTERED APPROACH
Prepared by: Dr. K. Robinson

2. DIABETES MELLITUS

3. ■ Patient M.L. is a 32-year old female, presenting to her primary care
health center with complaints of polyuria for the past four weeks.
■ Further assessment reveals an upcoming appointment with an
ophthalmologist for new onset blurred vision.
■ The patient is 165.1 cm tall and weighs 64.4 kg; her calculated BMI
is 23.6 kg/m2.
■ She confirms a family history of diabetes on her father's side and
admits to a generally sedentary occupation and lifestyle.
■ A random finger stick reveals a blood glucose level of 14.3 mmol/L.

4. Diagnosis of Diabetes Mellitus
Diagnosis/Test ADA 2021 WHO 2006/2011
Diabetes
Random Blood Glucose ≥ 11.1mmol/l (200mg/dL) plus
osmotic symptoms
≥ 11.1mmol/l (200mg/dL) plus
osmotic symptoms
Fasting Plasma Glucose ≥ 7.0mmol/l (126mg/dL) ≥ 7.0mmol/l (126mg/dL)
2-hour Post-prandial ≥ 11.1mmol/l (200mg/dL) ≥ 11.1mmol/l (200mg/dL)
HbA1c ≥ 6.5 ≥ 6.5

5. Prediabetes

6. Patient M.L.’s evaluation has resulted in
adequate findings to diagnose diabetes. Any
random blood glucose ≥ 11.1mmol/l (200
mg/dL) with additional symptoms (in this
case, polyuria and blurred vision) is
considered diagnostic for diabetes mellitus.

7. Laboratory Evaluation
■ Glucose profile (fasting and postprandial glucose values)
■ HbA1c, if results not available within the past 3 months
■ Lipid profile
■ Liver function tests
■ Urea & Electrolytes, including uric acid
■ Spot urine albumin to creatinine ratio
■ TSH in type 1 diabetes, or women over 50 years
■ Beta cell antibodies (e.g. anti-GAD 65) in patients less than
45 years at diagnosis
■ Urine Ketones*

8. Patient M.L.’s Lab Results:
■ HbA1c: 8.5% ⬆
■ Fasting plasma glucose: 8.1 mmol/l ⬆
■ 2hr glucose level: 13.3 mmol/l ⬆
■ Cholesterol: 4.8 mmol/l (1.2-5.2 mmol/l)
■ Triglycerides: 8.4 mmol/l ⬆ (0.20-1.70 mmol/l)
■ LDL: 5.3 mmol/l ⬆ (0.5-3.4 mmol/l)
■ HDL: 1.9 mmol/l (1.0-2.2 mmol/l)
■ Complete Blood Count: WNL
■ Liver function tests: WNL
■ Renal function: WNL

9. What’s the next best option in
patient M.L.’s management?
A. Commence insulin therapy and review x 3/12
B. Trial of diet & lifestyle modification and review x 3/12
C. Start metformin 500mg p.o. b.d. and review in 3/12
D. Site IV access, bolus 500cc 0.9% NS and refer to nearest
hospital
E. No treatment needed at this time

10. Answer B: Trial of diet & lifestyle
modification and review x 3/12
■ Patient ML is counselled on diabetes, its
complications and the necessary diet and
lifestyle modifications.
■ Additionally, M.L. is referred to a Diabetes
Educator for further education in diabetes self-
management, self-monitoring of blood glucose,
and exercise and meal planning education.

11. What is diet &
lifestyle modification?

12. Diet & Lifestyle Modifications for
Diabetes Prevention of Delay of
Onset
■ Nutrition Therapy:
– An integral part of a healthy, sustained weight loss program is
the subtraction of calories each day from the diet.
– For most patients, weight loss diets should supply at least 1,000
to 1,200 kcal/day for women and 1,200 to 1,600 kcal/day for
men.
– Total fat should be 25 to 35 percent of total calories and
saturated fat less than 7 percent.
– Portion control is essential for weight loss.

13. Diet & Lifestyle Modifications for
Diabetes Prevention of Delay of
Onset
■ Physical Activity:
– Patients should get at least 30 minutes of moderate-
intensity physical activity five days a week.
– Daily activity time can be broken into segments.
– Brisk walking is an excellent form of moderate-intensity
physical activity.

14. Diet & Lifestyle Modifications for
Diabetes Prevention of Delay of
Onset
■ Weight Loss:
– Both ADA and WHO recommend realistic yet
clinically meaningful weight loss goals.
– 5-7% reduction in initial weight (10 to 14 pounds
(4.5 to 6.3 kg) for a 200-pound (90.6 kg) person
over one year.

15. Diet & Lifestyle Modifications for
Diabetes Prevention of Delay of
Onset
■ Behavior Therapy:
– Effective behavioral strategies that patients can use in
their efforts to modify their lifestyles include:
• self-monitoring, stress management, stimulus control,
• problem-solving, self-directed goal-setting,
• cognitive restructuring, and social support.
– Behavioral therapies may help adoption of diet and activity
changes.

16. Diet & Lifestyle Modifications for
Diabetes Prevention of Delay of
Onset
■ Follow-up and referral:
– A focus on improved glucose and cholesterol levels,
blood pressure, and self-esteem can reinforce the
importance of lifestyle changes that lead to modest
weight loss.
– Referral to specialist physicians, registered dietitians
and other associated healthcare professionals can help
patients maintain lifestyle changes.

19. ■ Patient M.L. returns after three months.
■ Her follow-up HbA1c demonstrates minimal change, with a result
of 8.2%.
■ Fasting plasma glucose level of 8.6 mmol/l.
■ Self-monitoring GMR records reveal blood glucose levels between
7.5 mmol/l and 8.8 mmol/l fasting and between 12.8 mmol/l and
16.6 mmol/l 2hr postprandial.
■ Patient M.L. states that she is following her meal and exercise
planning goals with little success.

20. ■ The physician determines that the best course of treatment would be to
initiate metformin 500mg p.o. b.d, at this time and to review x 3/12.
■ The continuation with her meal and exercise plans, as before, is
emphasized.
■ M.L. returns again after three months.
■ Fasting plasma glucose the morning of clinic appointment is 7.9
mmol/l.
■ Her self-monitoring GMR records again show blood glucose levels
consistently between 7.5 mmol/l and 8.8 mmol/l fasting and between
12.8 mmol/l and 16.6 mmol/l 2hr postprandial.

21. What is the next best treatment
option to attain glycemic control?
A. Increase the dose of metformin to 1g p.o. b.d.
B. Consider insulin-based therapy
C. Refer to Endocrine Clinic
D. Commence dual anti-diabetic drug therapy
E. Send the patient home with encouragement

22. Answer D: Commence dual anti-
diabetic drug therapy

24. ■ Patient M.L. is started on glipizide 5 mg (a sulfonylurea) each
morning.
■ This is an appropriate treatment plan because, although she has a
sedentary occupation, she is not considered obese.
■ She has been adherent to her meal and exercise plan without
success.
■ Her fasting blood glucose levels are elevated, but it is the
postprandial levels that have instigated the elevated HbA1c levels.
■ The sulfonylurea secretagogue glipizide should improve the high
postprandial levels resulting from loss of first-phase insulin release.

25. ■ M.L. returns for a review; it has been five months since her last
visit.
■ Blood investigations reveal HbA1c 6.1%, FPG 5.9 mmol/l and 2hr-pp
7.4 mmol/l
■ She has lost 12lbs (5.5 kg) over these 11-months.
■ She is sent to do other routine screening tests for DM and is TCA x
3/12 with these results for review.
■ She follows-up with her ophthalmologist privately.

26. Source:
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd
=&cad=rja&uact=8&ved=2ahUKEwjLkqvBher2AhUphOAKHYKrAWMQFno
ECAYQAQ&url=https%3A%2F%2Fclinical.diabetesjournals.org%2Fconten
t%2F38%2F1%2F10.full-
text.pdf&usg=AOvVaw0vULrGQSYVdUn61BRLbW4M

27. HYPERTENSION

28. ■ Patient D.G. is a 40-year old male of African descent who present to his
health center with a sore left ankle after a game of football.
■ He has no significant past medical history. Previous presentations have been
related to coughs and colds.
■ He smokes 25 cigarettes a day, alcohol consumption around 20 units/week
and has done for 18 years.
■ He works shifts as a security guard and says that he considers his diet to be
unhealthy as a result.
■ O/E: Nil distress. MM pink + moist. AI, AC, AF
– BP 150/92 mmHg [RC 149/91 mmHg], P 76bpm, R 20breaths/min, T 36.7°C
– Examinations findings significant only to MSK: findings suggestive of a
sprained ankle.

29. Diagnosis of Hypertension
■ Most of the current guidelines define hypertension (HTN) as
systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood
pressure (DBP) ≥ 90 mmHg.
– The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC-7).
– European Society of Cardiology (ESC) and European Society of
Hypertension (ESH)
■ In 2017, The American College of Cardiology (ACC) and the
American Heart Association (AHA) recommended that HTN be
defined as SBP ≥ 130 mmHg or DBP ≥ 80 mmHg.

30. SBP CLASSIFICATION DBP CLASSIFCATION
SBP (mmHg) JNC-7 (2003) ACC/AHA
(2017)
ESC/ESH
(2018)
DBP (mmHg) JNC-7 (2003) ACC/AHA
(2017)
ESC/ESH
(2018)
<120 Normal Normal Optimal <80 Normal Normal Optimal
120-129 Pre-
hypertension
Elevated
Blood
Pressure
Normal 80-84 Pre-
hypertension
Stage 1
hypertension
Normal
130-139 Stage 1
hypertension
High Normal 85-89 High Normal
140-149 Stage 1
Hypertensio
n
Stage 2
hypertension
Grade 1
Hypertensio
n
90-99 Stage 1
hypertension
Stage 2
hypertension
Grade 1
Hypertensio
n
150-159 Grade 2
hypertension
100-109 Stage 2
hypertension
Grade 2
Hypertensio
n
≥ 160 Stage 2
hypertension
Grade 3
Hypertensio
n
≥ 110 Grade 3
Hypertensio
n

31. Source: https://cdn.mdedge.com/files/s3fs-public/Image/June-
2018/JFP06707416_t2.jpg

32. Diagnosis of Hypertension
■ The classification using the JNC-7 cut off points is based on office
blood pressure measurement (OBPM) levels.
■ Diagnosis SHOULD NOT be based solely on values from a single
encounter unless patients present with findings of a hypertensive
urgency or hypertensive emergency.
■ It is now widely accepted that ambulatory blood pressure monitoring
(ABPM) and home blood pressure monitoring (HBPM) are both useful
adjuncts to office blood pressure monitoring.
■ Where ABPM and HBPM are used the cut points for classification are
lower.

33. Source:
https://www.portailvasculaire.fr/sites/default/files/docs/2020_ish_guidelines_hta_hypertension.pdf

34. Diagnosis of
Hypertension
Source: https://ish-
world.com/data/uploads/ISH_Guideline_Presentation_Slide_Deck_06.05.2020.pdf

35. ■ In order to diagnosis HTN, D.G. is asked to undertake HBPM to
confirm a diagnosis.
■ He is to ensure that at least two BP readings are logged each day
(once in the morning and another in the evening).
■ At the same time, investigations for end-organ damage (such as left
ventricular hypertrophy, chronic kidney disease and hypertensive
retinopathy) are carried out.
■ What routine laboratory tests are recommended prior
to initiation of therapy?

36. Laboratory Evaluation
■ Urinalysis & microscopy: urinary protein, albumin, blood,
abnormal urinary sediments
■ Albumin: creatinine ratio, urine sodium, urine creatinine, FENa,
eGFR
■ CBC
■ U&E and extended chemistry
■ Lipid profile
■ Blood sugar: fasting and 2-hr postprandial plasma glucose
■ Chest X-ray, as indicated
■ Electrocardiography: 12-lead electrocardiogram (ECG)
■ Abdominal ultrasonography, as indicated

37. Target/End-Organ Disease Secondary to
HTN
Vascular Disease Cerebrovascular Disease
Endothelial dysfunction
Atherosclerosis
Arterial stenosis & Aneurysms
Transient Ischaemic Attack (TIA)
Ischaemic stroke
Haemorrhagic stroke
Renal Disease Heart Disease
Albuminuria
Proteinuria
Chronic renal impairment
Renal failure
Left ventricular hypertrophy
Coronary microangiopathy
Coronary artery disease
Myocardial infarction
Arrhythmias (e.g. atrial fibrillation)
Congestive heart failure

38. Given D.G.’s history provided, what diet
and lifestyle modifications would be
recommended at this time to lower his
blood pressure?

39. Modification Recommendation Application Approximate
BP Reduction
Being More
Physically Active
An accumulation of 30-60 minutes of
dynamic exercise of moderate intensity
(e.g. walking, cycling, swimming) 5-7
days per week in addition to the routine
activities of daily living.
Prescribe to both normotensive
and hypertensive individuals for
prevention and management of
HTN, respectively.
4-9 mmHg
Weight Reduction A healthy BMI (18.5-24.9 kg/m2) and
waist circumference (<102cm for men
and <88cm for women) is recommended
for non-HTN individuals to prevent HTN
and for HTN patients to reduce BP.
Encourage multidisciplinary
approach to weight loss including
dietary education, increased
physical activity and behavior
modification.
5-10 mmHg/
10kg
Lower Sodium Intake • Consume no more than 2,400 mg of
sodium/day.
• Reduction of sodium intake to
1,500mg/day is ideal.
Prescribe to both normotensive
and hypertensive individuals for
prevention and management of
HTN, respectively.
2-8 mmHg
Eat Healthier/ Adopt
DASH Eating Plan
DASH-like diet:
• High in fresh fruits, vegetables,
dietary fiber, non-animal protein (e.g.
soy), and low-fat dairy products.
• Low in saturated and total fat.
Prescribe to both normotensive
and hypertensive individuals for
prevention and management of
HTN, respectively.
8-14 mmHg

40. Modification Recommendation Application Approximate BP
Reduction
Moderation in Alcohol
Intake
Limit consumption to no more than 2
drinks (e.g. 24oz beer, 10oz wine, or
3oz 80-proof Whiskey) per day in
most men, and to no more than 1
drink per day in women and lighter
weight persons.
Prescribe to both
normotensive and
hypertensive individuals for
prevention and management
of HTN, respectively.
2-4 mmHg
Smoking Cessation Advise smokers to quit and offer
specific pharmacotherapy to help
them.
Abstinence from smoking. A smoke-
free environment.
Global cardiovascular risk
reduction strategy
10-15 mmHg
Relaxation Therapy Individualized cognitive behavior
interventions are more likely to be
effective when relaxation techniques
and meditation are employed.
Prescribed for selected
patients in whom stress plays a
role in elevating BP.
1-2 mmHg
Source: AHA/ACC/CDC Science Advisory: An Effective Approach to High Blood Pressure Control.
Hypertension. 2013; doi:10.1161/HYP.0000000000000003

41. ■ D.G. returns for review after three months.
■ HBPM indicates that D.G.’s average blood pressure is 148/96 mmHg.
■ There is no evidence of end-organ damage during history and
examination.
■ He claims adherence to diet and lifestyle modifications with the
exception of smoking cessation.
■ The results of the tests/investigations ordered have returned. All are
WNL with the exception of his total cholesterol of 5.6 mmol/l ⬆ (1.2-
5.2 mmol/l). HDL 1.1 (1.0-2.2 mmol/l).
■ His 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 7.3%
(borderline risk).

42. What is the next best option to aid in
the management strategy of D.G?
A. Smoking cessation
B. Refer to A&E for BP control
C. Further evaluation via specialist assessment
D. Carvedilol 6.25mg p.o. b.d.
E. No other treatment intervention necessary

43. Answer C: Further evaluation via
specialist assessment
■ Consider seeking specialist evaluation of secondary causes of
hypertension and/or a more detailed assessment of potential
end-organ damage (e.g. ECHO, Stress Test).
■ Individuals 40 years and under with stage 1 hypertension are
less likely to have overt evidence of end-organ damage or
vascular disease.
■ The 10-year cardiovascular risk assessments can underestimate
the lifetime risk of cardiovascular events in these individuals.

44. ■ D.G. returns with the results of the specialist assessment.
■ There are no secondary causes of hypertension; however, he
was noted to have left ventricular hypertrophy and early
evidence of impaired diastolic relaxation on his
echocardiogram.
■ The report suggests that these changes are most likely related
to hypertension.
■ Thus, D.G. has evidence of end-organ damage.
■ What should be done now for D.G.?

45. Recommended drugs for the
management of HTN:
Source: https://www.moh.gov.jm/wp-

46. Recommended drugs for the
management of HTN:
Source: https://www.moh.gov.jm/wp-

47. White Coat and Masked Hypertension
■ White Coat HTN is seen in individuals who have elevated BP
readings only in the office, and non-elevated out-of-office
(ABPM or HBPM) BP measurements.
■ Masked HTN is seen in individuals who have non-elevated BP
in the office, but elevated BP readings out-of-office (ABPM
or HBPM).
■ According to WHO, ~10-30% of patients attending clinics due
to elevated BP have White Coat HTN and ~10-15% have Masked
Hypertension.

48. Source: https://ish-world.com/data/uploads/ISH_Guideline_Presentation_Slide_Deck_06.05.2020

49. References
■ American Diabetes Association; Standards of Medical Care in Diabetes—2022 Abridged for Primary Care
Providers. Clin Diabetes 1 January 2022; 40 (1): 10–38.
https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-
2022 (Accessed on 28/03/2022).
■ Armstrong C; Joint National Committee. JNC-8 guidelines for the management of hypertension in adults. Am
Fam Physician. 2014 Oct 1;90(7):503-4. PMID: 25369633. https://www.aafp.org/afp/2014/1001/p503.html
(Accessed on 28/03/2022)
■ Diabetes Education Online. Treatment Goals of Diabetes. Diabetes Teaching Center at the University of
California, San Francisco.
https://dtc.ucsf.edu/types-of-diabetes/type2/understanding-type-2-diabetes/basic-facts/treatment-
goals/ (Accessed on 28/03/2022).
■ International Society of Hypertension (ISH). 2020 ISH Global Hypertension Practice Guidelines. May 2020.
https://ish-world.com/data/uploads/ISH_Guideline_Presentation_Slide_Deck_06.05.2020.pdf (Accessed
on 28/03/2020)
■ Ministry of Health and Wellness Jamaica. Interim Guidelines for the Clinical Management of Diabetes in
Jamaica. August 2020. https://www.moh.gov.jm/wp-
content/uploads/2020/10/DIABETESGUIDELINES_Interim_final.pdf (Accessed on 28/03/2022).
■ Ministry of Health and Wellness Jamaica. Interim Guideline for the Clinical Management of Hypertension in
Jamaica. July 2020.
https://www.moh.gov.jm/wp-content/uploads/2020/10/HYPERTENSIONGUIDELINES_Interim_final.pdf
(Accessed on 28/03/2022)
■ World Health Organization (WHO). Definition and Diagnosis of Diabetes Mellitus and Intermediate
Hyperglycemia. Report of a WHO/IDF Consultation. July 2006.
https://www.who.int/diabetes/publications/Definition%20and%20diagnosis%20of%20diabetes_new.pdf
(Accessed on 28/03/2022).

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