Healthy lifestyles for patients with hypertension. A noncommunicable disease education manual for primary health care professionals and patients

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1 Healthy lifestyles for patients with hypertension A noncommunicable disease education manual for primary health care professionals and patients

3 Healthy lifestyles for patients with hypertension A noncommunicable disease education manual for primary health care professionals and patients

4 The Noncommunicable Disease Education Manual for Primary Health Care Professionals and Patients results from the contributions and hard work of many people. Its development was led by Dr Hai-Rim Shin, Coordinator, and Dr Warrick Junsuk Kim, Medical Officer, of the Noncommunicable Diseases and Health Promotion unit at the WHO Regional Office for the Western Pacific (WHO/WPRO/NCD) in Manila, Philippines. WHO graciously acknowledges the intellectual contributions of Dr Jung-jin Cho, Co-director, Community-based Primary Care Project Committee and Professor, Department of Family Medicine, Hallym University Sacred Heart Dongtan Hospital, Republic of Korea; Dr Hyejin Lee, Volunteer, WHO/WPRO/NCD (currently PhD candidate, Department of Family Medicine, Seoul National University, Republic of Korea); Ms Saki Narita, Volunteer, WHO/WPRO/NCD (currently PhD candidate, Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan); and Mr Byung Ki Kwon, Technical Officer, WHO/WPRO/NCD (currently Director, Division of Health Promotion, Ministry of Health and Welfare, Republic of Korea). Many thanks to Dr Albert Domingo, Dr Sonia McCarthy, Ms Marie Clem Carlos, Dr Katrin Engelhardt, Mr Kelvin Khow Chuan Heng and Dr Roberto Andres Ruiz from the WHO Regional Office for the Western Pacific and Dr Ma. Charina Benedicto, Physician-in-Charge, Bagong Barangay Health Center & Lying-in Clinic, Pandacan, Manila, Philippines for reviewing the draft publication. Financial support for this publication was received from the Korea Centers for Disease Control and Prevention, Republic of Korea. No conflict of interest was declared. This is a translation of a manual published by the Ministry of Health and Welfare and Community-based Primary Care Project Committee in the Republic of Korea. Some of the content has been adapted, with permission, to align with current WHO recommendations and policies. However, the views expressed in the manual do not necessarily reflect the policies of the World Health Organization. The source publication was developed under the leadership of Dr Jung-jin Cho (also mentioned above); Mr Hyunjun Kim, Co-director, Community-based Primary Care Project Committee and Director General, Bureau of Health Policy, Ministry of Health and Welfare, Republic of Korea; and Dr Sunghoon Jung, Deputy Director, Division of Health Policy, Ministry of Health and Welfare, Republic of Korea. All illustrations were provided by the source publication. Photo credits WHO: pages 29, 30 Shutterstock: pages 3-12, 25, 26 ISBN World Health Organization 2017 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.

5 Noncommunicable disease education manual for primary health care professionals and patients Part 1 Part 2 Part 3 Prevention and management of hypertension Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7 Prevention and management of diabetes Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7 Quit smoking Diagnosis and management Healthy lifestyles YOU ARE HERE Healthy eating habits Low-salt diet Physical activity Medication and management of associated diseases Complication prevention Diagnosis and management Healthy lifestyles Healthy eating habits 1 Healthy eating habits 2 Physical activity Taking care of yourself in daily life Complication prevention

6 Under mmhg Under *Age more than 80: blood pressure to be controlled below 150/90 mmhg REFERENCE: James, Paul A., et al evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 2014, 311.5: How to use this manual This book is one of fifteen modules of the Noncommunicable disease education manual for primary health care professionals and patients. This manual is intended to provide health information on the prevention and control of hypertension and diabetes. This will be used in the form of a flip chart for health professionals to educate their patients with either hypertension or diabetes. Blood pressure target Systolic blood pressure Under 140 mmhg Diagnosis and management for patients with hypertension Diastolic blood pressure Under 90 mmhg FOR PATIENTS On one side of the flip chart is the For patients page. This side has simple images and key messages that are easy to understand. However, health professionals may need to provide education for patients to fully understand the content. *Age more than 80: blood pressure to be controlled below 150/90 mmhg FOR PATIENTS Blood pressure target Patient education Blood pressure below 140/90 mmhg is generally advised to prevent complications. However, blood pressure targets can be adjusted according to age, number and type of risk factors, and associated diseases. Therefore, if you have hypertension, you should consult your physician to set a target after evaluating your current health status and risk factors. Systolic blood Diastolic blood pressure pressure mmhg Diagnosis and management for patients with hypertension Professional information Target blood pressure According to the Eighth Joint National Committee (JNC8), those over age 80 are advised that their target blood pressure should be below 150/90 mmhg. Target blood pressure should be below 140/90 mmhg for hypertension combined with cerebrovascular disease and atherosclerosis. For those under age 80 maintain below 140/90 mmhg; those over age 80 maintain below 150/90 mmhg. FOR PHYSICIANS On the other side of the flip chart is the For physicians page. This side includes information that the health professional can read out to the patient during counselling. Professional information is also provided for further understanding. A small image of the For patients side is included so that the health professional is aware of what the patient is looking at. FOR PHYSICIANS This publication is intended to serve as a template to be adapted to national context. Images and graphs that have been watermarked should be replaced with images or graphs that represent the national situation. If assistance is required, or if you have any questions related to the publication, please contact the Noncommunicable Diseases and Health Promotion unit at WHO Regional Office for the Western Pacific (wproncd@who.int).

7 Table of contents Module 2 Healthy lifestyles for patients with hypertension Healthy lifestyles for patients with hypertension Eat healthy (low-salt diet) Eat healthy (low-fat diet) Eat healthy (high-fibre diet) Choose healthy carbohydrates Dietary management Effect of physical activity on hypertension Before you start physical activity Good exercises for patients with hypertension Exercises to avoid Smoking and hypertension Alcohol and hypertension Stop harmful use of alcohol How to stop harmful use of alcohol Managing your stress Take-home message

displayed Eat healthy Be physically active Stop harmful

8 Healthy lifestyles for patients with hypertension INSERT PHOTO: example of how a typical local meal would be displayed Eat healthy Be physically active Stop harmful use of alcohol Quit smoking Manage your stress 1 FOR PATIENTS

Healthy lifestyles for patients with hypertension Patient education Maintaining a healthy lifestyle is necessary for patients with hypertension. It is mandatory.

9 Healthy lifestyles for patients with hypertension Patient education Maintaining a healthy lifestyle is necessary for patients with hypertension. It is mandatory. The following information covers dietary management, exercise, smoking, drinking and stress management. INSERT PHOTO: example of how a typical local meal would be displayed Eat healthy Be physically active Quit smoking Stop harmful use of alcohol Manage your stress REFERENCES: National Institutes of Health, and National Heart, Lung, and Blood Institute. Your guide to lowering blood pressure. NIH publication, 2003, Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: FOR PHYSICIANS

high in salt INSERT PHOTO: example of local foods high in salt INSERT

10 Eat healthy (low-salt diet) Eat less soup broth Eat less pickled and processed food Eat fresh, local food INSERT PHOTO: example of local foods high in salt INSERT PHOTO: example of local foods high in salt INSERT PHOTO: example of fresh local food (salad) with no dressing or sauce added 3 FOR PATIENTS

11 Eat healthy (low-salt diet) Patient education A balanced diet is very important for people with hypertension. It is also vital to eat less salt. For example, instead of drinking the soup broth, eat only the ingredients in the soup. Also cut back on pickled and processed foods like ketchup, sausage and ham. It is highly recommended to eat fresh and healthy local food. Eat less soup broth Eat less pickled and processed food Eat fresh, local food INSERT PHOTO: example of local foods high in salt INSERT PHOTO: example of local foods high in salt INSERT PHOTO: example of fresh local food (salad) with no dressing or sauce added REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: James, Paul A., et al Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 2014, 311.5: Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute (United States). Your guide to lowering your blood pressure with DASH. DASH eating plan, FOR PHYSICIANS

Milk, dairy products: eat low-fat or fat-free milk INSERT PHOTO:

12 Eat healthy (low-fat diet) Meat: remove skin, trim fat, reduce processed meat intake Reduce liver, intestine intake. Milk, dairy products: eat low-fat or fat-free milk INSERT PHOTO: example of local foods high in fat INSERT PHOTO: example of local foods high in fat 5 FOR PATIENTS

Eat healthy (low-fat diet) Patient education It is important to cut down on fat because many patients with hypertension have dyslipidaemia and need to control their weight.

13 Eat healthy (low-fat diet) Patient education It is important to cut down on fat because many patients with hypertension have dyslipidaemia and need to control their weight. When you eat meat, trim the fat. Reduce liver, intestine and processed meats consumption. Choose low-fat or fat-free dairy products. Meat: remove skin, trim fat, reduce processed meat intake Reduce liver, intestine intake. Milk, dairy products: eat lowfat or fat-free milk INSERT PHOTO: example of local foods high in fat INSERT PHOTO: example of local foods high in fat REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: James, Paul A., et al Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 2014, 311.5: National Institutes of Health, and National Heart, Lung, and Blood Institute (United States). Your guide to lowering blood pressure. NIH publication, 2003, FOR PHYSICIANS

reduces the incidence of complications and cancer.

14 Eat healthy (high-fibre diet) Dietary fibre prevents cholesterol absorption and production. reduces the absorption rate of carbohydrates. reduces the incidence of complications and cancer. aids the digestive process. is abundant in vegetables, fruits, grains and seaweeds. 7 FOR PATIENTS

Eat healthy (high-fibre diet) Patient education Fibre also prevents absorption and production of cholesterol and has the positive effect of reducing the absorption rate of carbohydrates, as well as

15 Eat healthy (high-fibre diet) Patient education Fibre also prevents absorption and production of cholesterol and has the positive effect of reducing the absorption rate of carbohydrates, as well as the incidence of constipation and cancer. Foods high in fibre are fruits, vegetables, oats, dry beans, seaweeds and grains. Eating fibre has benefits, such as aiding weight loss, even if it does not reduce blood pressure directly. Some studies report a decrease in blood pressure as a result of eating more dietary fibre, but this needs more research. Dietary fibre prevents cholesterol absorption and production. reduces the absorption rate of carbohydrates. reduces the incidence of complications and cancer. aids the digestive process. is abundant in vegetables, fruits, grains and seaweeds. REFERENCES: McGuire, Shelley. U.S. Department of Agriculture and U.S. Department of Health and Human Services (United States), Dietary Guidelines for Americans, Advances in Nutrition: an international review journal, 2011, 2.3: Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute (United States). Your guide to lowering your blood pressure with DASH. DASH eating plan, FOR PHYSICIANS

Choose healthy carbohydrates Excessive carbohydrates increase in triglycerides Accumulation of fatty acids obesity, arteriosclerosis Instead

16 Choose healthy carbohydrates Excessive carbohydrates increase in triglycerides Accumulation of fatty acids obesity, arteriosclerosis Instead of white rice, instant noodles and white bread, choose brown rice, rye bread and potatoes. white rice multi-grain bread brown rice 9 FOR PATIENTS

17 Choose healthy carbohydrates Patient education Moderate intake of carbohydrates is recommended because they can increase serum triglyceride, obesity and arteriosclerosis. It is recommended to eat brown rice and whole grain bread rather than carbohydrates with a high glycemic index such as white rice, instant noodles and white bread. Excessive carbohydrates increase in triglycerides Accumulation of fatty acids obesity, arteriosclerosis Instead of white rice, instant noodles and white bread, choose brown rice, rye bread and potatoes. white rice multi-grain bread brown rice REFERENCES: American Diabetes Association. Standards of medical care in diabetes Diabetes Care, International Diabetes Federation. Global guideline for type 2 diabetes. Brussels: IDF Clinical Guidelines Task Force, FOR PHYSICIANS

18 Dietary management Caution in caffeine intake Abundant in coffee, black tea, caffeinated sodas and energy drinks, and dark chocolate Caffeine temporarily increases blood pressure Not more than two cups of coffee per day Intake of caffeine before exercise is not advised 11 FOR PATIENTS

19 Dietary management Patient education Caffeine is abundant in most teas, caffeinated sodas, energy drinks and chocolate. Caffeine temporarily increases blood pressure, so it is better to reduce consumption. It is normally recommended to drink no more than two cups of coffee per day. Caffeine intake should be avoided before exercising because it raises blood pressure dramatically in a short time. This can result in light-headedness, dizziness or fainting, and these effects can be much worse if a person already has high blood pressure or another heart condition. Caution in caffeine intake Abundant in coffee, black tea, caffeinated sodas and energy drinks, and dark chocolate Caffeine temporarily increases blood pressure Not more than two cups of coffee per day Intake of caffeine before exercise is not advised REFERENCE: Evidence-based recommendations for hypertension in primary care. Korean Medical Guideline Information Center, 2014 ( accessed 28 September 2016). 12 FOR PHYSICIANS

20 Effect of physical activity on hypertension Reduced blood pressure Controlled body weight Less stress Decreased cardiovascular disease 13 FOR PATIENTS

21 Effect of physical activity on hypertension Patient education Adequate exercise is helpful in reducing blood pressure, weight reduction and stress relief, and reduces risk of cardiovascular disease. Therefore, regular exercise is as important as antihypertensive drugs. Reduced blood pressure Body weight control Decreased cardiovascular disease Less stress REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: National Institutes of Health, and National Heart, Lung, and Blood Institute (United States). Your guide to lowering blood pressure. NIH publication, 2003, Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: FOR PHYSICIANS

Before you start physical activity If you have any of the following, consult your doctor: Heart disease Bone or joint problems that could be made worse with

22 Before you start physical activity If you have any of the following, consult your doctor: Heart disease Bone or joint problems that could be made worse with vigorous physical activity Chest pain Dizziness Age of 65 years or older Uncontrolled hypertension Any other reasons why you should not do physical activity 15 FOR PATIENTS

23 Before you start physical activity Patient education If you have been diagnosed with heart disease or musculoskeletal disorder (such as injuries or pain in your tendons or joints), consult your doctor before beginning any exercise. If you have chest pain or frequent dizziness, or if you are over 65, you should also discuss this with your doctor. If you have uncontrolled hypertension and any other reasons why you should not engage in physical activity, please consult your doctor. Professional information The previous patient education section is from Canada s Physical Activity Readiness Questionnaire (PAR-Q), designed to identify those who have health problems before exercising. The Physical Activity Readiness Medical Examination (PARmed-X) is an updated version. ( uploads/2015/08/parmed-x.pdf) If you have any of the following, consult your doctor: Heart disease Bone or joint problems that could be made worse with vigorous physical activity Chest pain Dizziness Age of 65 years or older Uncontrolled hypertension Any other reasons why you should not do physical activity 16 FOR PHYSICIANS

24 Good exercises for patients with hypertension Aerobic exercise Strengthens heart and lung function Strengthens joints and increases body flexibility Strengthens bones and muscles Examples of recommended exercises Walking/ Jogging Running Cycling Swimming 17 FOR PATIENTS

25 Good exercises for patients with hypertension Patient education There are particular exercises that are recommended for patients with hypertension. Aerobic exercise, such as brisk walking, jogging, running, cycling, swimming or other simple physical exercises are beneficial. Exercise 5 7 days a week for at least 30 minutes each day. Benefits of aerobic exercise see below. Aerobic exercise Strengthens heart and lung function Strengthens joints and increases body flexibility Strengthens bones and muscles Examples of recommended exercises Walking/ Jogging Running Cycling Swimming REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: National Institutes of Health, and National Heart, Lung, and Blood Institute (United States). Your guide to lowering blood pressure. NIH publication, 2003, Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: FOR PHYSICIANS

26 Exercises to avoid 19 FOR PATIENTS

harmful to patients with uncontrolled hypertension. Sudden straining is hazardous.

27 Exercises to avoid Patient education Avoid weightlifting that requires explosive strength, or rowing and diving requiring the head to be positioned low these could be harmful to patients with uncontrolled hypertension. Sudden straining is hazardous. REFERENCE: Mayo Clinic ( accessed 28 September 2016). 20 FOR PHYSICIANS

Smoking and hypertension Smoking is the most important risk factor for chronic lung disease, cancer, cardiovascular disease, stroke and peripheral vascular disease.

28 Smoking and hypertension Smoking is the most important risk factor for chronic lung disease, cancer, cardiovascular disease, stroke and peripheral vascular disease. If you quit smoking, antihypertensive drugs become more effective. The risk of cardiovascular disease halves after a year of not smoking. The risk of cardiovascular disease becomes similar to non-smokers after 15 years of not smoking. 21 FOR PATIENTS

Smoking and hypertension Patient Education It is best to stop smoking. Smoking increases the risk of lung diseases, cancer and cardiovascular diseases such as angina and stroke.

29 Smoking and hypertension Patient Education It is best to stop smoking. Smoking increases the risk of lung diseases, cancer and cardiovascular diseases such as angina and stroke. If you wish to stop, but have failed, you can visit any clinic or doctor to get help. Smoking is the most important risk factor for chronic lung disease, cancer, cardiovascular disease, stroke and peripheral vascular disease. If you quit smoking, antihypertensive drugs become more effective. The risk of cardiovascular disease halves after a year of not smoking. The risk of cardiovascular disease becomes similar to non-smokers after 15 years of not smoking. REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: Department of Health and Human Services (United States). The health consequences of smoking 50 years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014, FOR PHYSICIANS

30 Alcohol and hypertension Harmful use of alcohol could cause: blood pressure to rise drug effectiveness to weaken unwanted side-effects of medication to increase malnutrition body weight to increase 23 FOR PATIENTS

31 Alcohol and hypertension Patient education Drinking alcohol lowers the effect of antihypertensive drugs and causes more side-effects. Alcohol also supplies many calories without any nutrition, disturbing body-weight management, so cutting alcohol intake is important. It is recommended that men limit drinking to less than two glasses a day and women limit drinking to less than one glass a day. Harmful use of alcohol could cause: blood pressure to rise drug effectiveness to weaken unwanted side-effects of medication to increase malnutrition body weight to increase REFERENCES: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: FOR PHYSICIANS

Stop harmful use of alcohol Maximum recommended daily amount of alcohol consumption 250 ml of beer INSERT

amount(ml) in one standard drink (10g) INSERT PHOTO: examples of frequently consumed alcoholic beverage;

of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink

32 Stop harmful use of alcohol Maximum recommended daily amount of alcohol consumption 250 ml of beer INSERT PHOTO: 100 ml of wine = = examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) INSERT PHOTO: examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) 25 ml of whisky INSERT PHOTO: examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) Male: 2 glasses or less Female: 1 glass or less One standard drink = 10 grams of pure alcohol 25 FOR PATIENTS

33 Stop harmful use of alcohol Patient education The recommended limit of alcohol consumption is half of that recommended for people without hypertension For men, daily alcohol consumption should be less than two glasses of alcohol. For women, consumption should be limited to under one glass per day. Professional information Men are recommended to limit consumption to less than two drinks (20 grams) of alcohol and women less than one drink (10 grams) of alcohol per day. 250 ml of beer INSERT PHOTO: Maximum recommended daily amount of alcohol consumption 100 ml of wine = = examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) INSERT PHOTO: examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) 25 ml of whisky INSERT PHOTO: examples of frequently consumed alcoholic beverage; also state name of alcohol and amount(ml) in one standard drink (10g) One standard drink = 10 grams of pure alcohol Male: 2 glasses or less Female: 1 glass or less REFERENCE: Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: FOR PHYSICIANS

34 How to stop harmful use of alcohol Drink no more than twice a week. Choose alcoholic beverages with low sugar. Avoid drinks with high alcohol level. 27 FOR PATIENTS

35 How to stop harmful use of alcohol Patient education It is best to drink no more than twice a week and to choose lower-calorie drinks (those with less sugar) wine or beer rather than champagne and cocktails. Avoid strong liquor and drinking on an empty stomach. Drink no more than twice a week. Choose alcoholic beverages with low sugar. Avoid drinks with high alcohol level. REFERENCE: National Hypertension Center, Republic of Korea. 28 FOR PHYSICIANS

36 Managing your stress Stress increases blood pressure and the risk of cardiovascular disease. The following can help manage stress: avoiding situations that cause stress regular exercise and adequate sleep 10-minute meditation finding a friend or a relative you can talk with. 29 FOR PATIENTS

37 Managing your stress Patient education Stress is harmful to those living with hypertension. Avoid stressful situations. Exercising regularly and regular 10-minute meditation are helpful in managing stress. It is also a good idea to find a friend you can talk over any issues with. Stress increases blood pressure and the risk of cardiovascular disease. The following can help manage stress: avoiding situations that cause stress regular exercise and adequate sleep 10-minute meditation finding a friend or a relative you can talk with. REFERENCES: Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: FOR PHYSICIANS

Take-home message Healthy lifestyles INSERT PHOTO: example of how a typical local meal would be displayed Eat healthy Eat less salt Eat a low-fat diet Be physically

38 Take-home message Healthy lifestyles INSERT PHOTO: example of how a typical local meal would be displayed Eat healthy Eat less salt Eat a low-fat diet Be physically active More than 150 minutes a week walking, cycling, swimming Quit smoking Stop harmful use of alcohol Maximum of one or two drinks per day Manage your stress 31 FOR PATIENTS

Healthy lifestyles for patients with diabetes. A noncommunicable disease education manual for primary health care professionals and patients

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