Some Fruits and Vegetables May Better Treat Hypertension than Others

Hypertension is very prevalent in the U.S. and worldwide. The condition can increase the risk for stroke and heart disease. Many American adults have hypertension, and it is not under control for a large number of these adults. Hypertension usually has no symptoms, so the only way to determine if a person has hypertension is by measuring their blood pressure. A number of diets that emphasize fruits and vegetables have been found to lower blood pressure. However, not a lot of attention has been paid to determining which fruits and vegetables, and which combinations of fruits and vegetables are most beneficial. And a recent study set out to do just that.

The study was a meta-analysis where the databases PubMed and Embase were searched for relevant studies, by the researchers, using search terms that contained  the keywords “fruits,” “vegetables,” and "hypertension." The researchers ended the search on May 15th 2022. The researchers extracted a total of 17566 articles. And after an exhaustive selection process, the researchers concluded that 18 studies met the inclusion criteria. Some of the elements of the criteria were relevance, case-control, the availability of full text rather than just the abstract, and how the title described the study.

Hypertension was the outcome of most of the studies. And most of the studies used the following hypertension guidelines: SBP ≥140 mm Hg and/or DBP ≥ 90 mm Hg, or SBP ≥ 135 mm Hg and/or DBP ≥85 mm Hg.” Some studies used a medical diagnosis of hypertension or a prescription for hypertension medication as a guideline. If a subject’s SBP was  ≥130 mm Hg, and/or the DBP ≥85 mm Hg, that subject was deemed to have elevated blood pressure

The researchers concluded that the results of this meta-analysis support dietary advice to increase the consumption of fruit and vegetables as part of strategies to prevent hypertension. The results show that a high intake of fruits and vegetables combined and total fruits, but not total vegetables, was associated with a lower risk of hypertension.

A daily intake of up to 800 grams of a combination of fruits and vegetables was associated linearly with hypertension prevention. And for some specific fruits and vegetables, such as cantaloupe, potatoes, and Brussels sprouts, there was an associated increased risk of hypertension, while apples, pears, avocado, blueberries, raisins or grapes, broccoli, carrots, lettuce, and onions appeared to lower the risk. Of course, more studies are needed to ferret out specific fruits and vegetables that are the most helpful in the treatment of hypertension.

Healthcare providers might want to investigate this study and other studies on diet to help the patient decide on the best diet to follow for hypertension.

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Plant-Based Diet Quality is Important for Cardiovascular Health

A leading cause of death and disability in the world is cardiovascular disease (CVD). Food has a vital influence on the development and management of cardiovascular disease. And reducing the consumption of animal products has been shown to have a positive impact on cardiovascular health. However, simply reducing meat intake is not enough. A focus on overall diet quality, including the consumption of a variety of plant-based foods, is essential for reducing cardiovascular risk.

Studies have consistently shown that a diet high in animal products, particularly red and processed meat, is associated with an increased risk of CVD. Animal products are high in saturated fats and cholesterol, which have been linked to an increased risk of CVD.

A diet filled with plant-based foods, like fruits, vegetables, whole grains, legumes, and nuts, has been shown to have a protective effect on cardiovascular health. These foods are high in fiber, antioxidants, and unsaturated fats, and have been linked to improved blood pressure and lipid profiles which can reduce the risk of CVD.

Indeed, individuals should select plant-based foods that are close to natural. The foods should be whole foods. These are foods that have received very little processing or refining. Whole foods typically contain no additives or artificial ingredients. Although individuals can select from animal products infrequently in moderation, individuals should abstain from eating fried foods such as fried poultry and fried fish. Also, when animal products such as low-fat dairy and eggs are consumed, these products should be eaten infrequently and in moderation.

Healthcare providers should discuss the importance of diet quality with their patients when discussion cardiovascular health. This is especially true for patients considering a plant-based diet. Patients should be warned not to assume that all plant-based diets will improve cardiovascular health, just because there is an absence of meat. The patients should be warned to avoid non-meat foods that have been processed or contain additives or artificial ingredients.

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Using Questionnaires to Predict Prediabetes and Diabetes Risk

Since prediabetes often leads to type 2 diabetes, a screening test, in the form of a questionnaire, is often used to identify individuals who are at risk for prediabetes and diabetes. Such a questionnaire, endorsed by the CDC and the ADA (American Diabetes Association), is used in the CDC National Diabetes Prevention Program. The questionnaire consists of five questions, some of which are related to cardiovascular health (CVH). And a recent study, examining the use of a questionnaire similar to the CDC/ADA questionnaire, has shown that there is a positive correlation between a high score on a CVH-related questionnaire and the development of prediabetes or diabetes.

An individual’s risk of prediabetes or diabetes increases with age, so a question requesting the individual’s age is on the CDC/ADA prediabetes-diabetes-risk questionnaire. Men have a higher risk of prediabetes and diabetes than women, so a gender-related question is on the questionnaire.

The risk of prediabetes and diabetes increases for women who experienced gestational diabetes, so a gestational-diabetes question is on the questionnaire. Questions are also asked about immediate family members who have had diabetes, since an immediate-family-history of diabetes can raise a person’s risks of diabetes and prediabetes.

Questions about weight and physical activity are also part of the questionnaire, since excess body fat and a lack of adequate physical activity can raise the risk of prediabetes and diabetes. A question concerning a diagnosis of high blood pressure is also on the questionnaire, since people with hypertension are at a high risk of diabetes.

The CDC/ADA questionnaire is a good predictor of prediabetes and diabetes risk. It is derived from a questionnaire the ADA published in 1995. And a recently developed questionnaire, using slightly different CVH metrics, also gives good indications of prediabetes and diabetes risk.

The more recent questionnaire is based on a CVH-related study investigating the use of a questionnaire to identify individuals with a high risk of acquiring prediabetes or diabetes. The study consisted of 403,857 participants who were 18-71 years of age. The researchers looked at fasting plasma glucose (FPG) data over a period of five consecutive years. And the researchers concluded that a group of CVH markers can be used to predict prediabetes and diabetes. Researchers, using the questionnaire, asks questions to determine if a person smokes, engages in physical activity, is overweight or obese, has untreated total cholesterol, high blood pressure or eats breakfast infrequently.

The researchers concluded that “The ideal CVH metrics were as follows: BMI of <25 kg/m2; non-smoking; 30 min of physical activity ≥twice weekly or ≥1 h of walking per day; ... skipping breakfast <3 times per week; systolic untreated blood pressure/diastolic blood pressure of <120/80 mmHg; and total cholesterol of <200 mg/dL”

Furthermore, the probability of acquiring prediabetes or diabetes increased as the number of non-ideal CVH metrics increased over a period of one year. And the association between a non-ideal BMI and the likelihood of prediabetes or diabetes was the strongest among the metrics.

Hence, healthcare providers should consider the use of questionnaires to help identify clients or patients who are at a high risk of prediabetes and diabetes.

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Healthcare Cost for Type 2 diabetes

The National Diabetes Prevention Program (National DPP) services can prevent or delay type 2 diabetes for individuals with prediabetes. The National DPP services include help with healthy diet, physical activity, and lifestyle modification. In delaying or preventing type 2 diabetes, the National DPP services can reduce healthcare costs.

Reducing healthcare costs is a significant concern with respect to diabetes. And since older people incur more healthcare costs, in general, one recent study looked at the cost of providing healthcare services to people with type 2 diabetes who were over 65. The CMS version of the National DPP, called the Medicare Diabetes Prevention Program, or MDPP, addresses diabetes prevention for Medicare beneficiaries, the majority of which are over 65 years of age.

In research conducted in Finland, investigators looked at "electronic patient records" to find people over 65 who had been told they had diabetes. After a selection process, 187 people with diabetes and 176 people without diabetes were chosen for the study. Information on how often primary care was used by the chosen participants was taken from electronic patient records for a one-year period.

It was found that, after a year, individuals with diabetes had more doctor's appointments, nurse's appointments, lab work done, and inpatient care at the community hospital than patients without a diagnosis of type 2 diabetes.

The older persons with type 2 diabetes who participated in these healthcare activities paid more for healthcare. In fact, the CDC reports that the average person with diabetes spends $16,750 a year on medical expenses. That is roughly 2.3 times what someone without diabetes would spend on medical care.

The National DPP and the MDPP (to some extent) are public-private arrangements that offer type 2 diabetes prevention services in healthcare and community settings. The National DPP and MDPP have been shown to decrease healthcare cost by delaying or preventing type 2 diabetes. To adequately address diabetes and type 2 diabetes prevention, healthcare providers should either offer treatment services or refer patients to community or healthcare organizations offering the services. 

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Handgrip Strength as a Predictor for Prediabetes

The commonly accepted definition of prediabetes, in general, is as follows: prediabetes is when an individual has abnormally high blood glucose, but the blood glucose is not high enough to be called diabetes. Prediabetes may affect the body in many ways. For example, according to a study done in India, prediabetes is associated with unwanted changes in handgrip strength. And a change in handgrip strength may come before the prediabetes. Indeed, one study, looking at subjects in Japan, indicates that handgrip strength could be an independent predictor of prediabetes.

In the India study, 200 subjects were examined. One hundred of the subjects had prediabetes and 100 had normal blood glucose. The researchers measured the handgrip strength of all subjects.

After crunching the data, the researchers found that the handgrip strength was approximately 12% less for the subjects with prediabetes compared to the subjects who had normal blood glucose.  So, handgrip strength decreased with prediabetes.

In the Japanese study, mentioned above, decreasing handgrip strength was shown to be a possible predictor of prediabetes. In the study, the researchers investigated 1075 subjects who had no prediabetes or diabetes. The researchers measured the handgrip strength of the subjects to obtain baseline measurements.  And the researchers used the handgrip strength measurements to calculate the relative handgrip strength. The relative handgrip strength is defined as "absolute handgrip strength (kg) divided by BMI (reported as kg/BMI)."

After two years of follow-up, the researchers concluded "that lower baseline relative handgrip strength predicted a higher risk of prediabetes incidence among the participants." The researchers stated that "relative handgrip strength predicted a lower and significant risk of prediabetes incidence among individuals with normal weight" as defined by a BMI between 18.4 and 25.

Therefore, handgrip strength measurements could be taken in healthcare settings. Those individuals who have low handgrip strength measurements could be examined for other indicators of prediabetes. And for those with prediabetes or a high risk for diabetes, appropriate interventions could be made.  

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The Diabetes Prevention Program Services Are Commercially Reimbursed

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a study to determine if lifestyle changes could prevent or delay type 2 diabetes. The study was called the Diabetes Prevention Program (DPP) trial. The researchers concluded that a relatively small amount of weight loss, along with healthy eating and physical activity, can prevent or delay type 2 diabetes for people with prediabetes. Based on the trial's results, the National Diabetes Prevention Program, or National DPP, was started and led by the CDC. However, there was very little reimbursement by commercial insurers for the program. However, today, there are a number of commercial insurers reimbursing for the program.

The Diabetes Prevention Program or DPP trial was started in 1996. The trial ended in 2001. The trial was a randomized study consisting of three groups. One of the groups, called the Intensive Lifestyle Intervention group, used diet, exercise and lifestyle modification for the prediabetes treatment. One of the groups, called the Metformin group, used metformin for the treatment. And one of the groups was the Placebo group which was treated with usual care approaches. To be included in the trial, a person had to have a BMI of at least 24, except for Asian American, who needed a BMI of at least 22. Results from the study were reported in 2002.

The specific goal of the study was to determine if individuals with prediabetes could avoid type 2 diabetes by losing 7% of their weight through diet, exercise, and lifestyle modification. During the average 2.8-year period of the study's participants, it was concluded that the intensive lifestyle group experienced a 58% reduction in the incidence of type 2 diabetes, and that the metformin group experienced a 31% reduction, compared to the placebo group. And after ten years, the type 2 diabetes incidence "was reduced by 34% ... in the lifestyle group and 18% .. in the metformin group compared with placebo."

And Medicare did its own study to see if the National DPP services would benefit Medicare beneficiaries. The study did show that Medicare beneficiaries could benefit from the National DPP services, so Medicare started the Medicare DPP or MDPP in 2018, with reimbursement for the DPP services. And today, a number of commercial insurers are reimbursing for the National DPP.

 

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CMS Has Made Improvements to the Medicare Diabetes Prevention Program

The Medicare Diabetes Prevention Program (MDPP) is an example of evidence-based Lifestyle Medicine (LM) methods that are being used to prevent and delay type 2 diabetes. And for 2024, CMS made changes to the MDPP to make the MDPP easier to navigate by the providers, more flexible, and more effective. After receiving much criticism concerning the MDPP, and after gaining experience during the COVID-19 PHE, CMS made changes to the MDPP to synch the program more with the National Diabetes Prevention Program (National DPP).

And if organizations, that provide the MDPP, structure their delivery process using the low-cost, group-based, evidence-based, DPP-coach-delivery model the National DPP is built on, the organizations can receive reimbursement that more than covers the cost of delivery (typically $400.00 to $500.00 per participant).

In the new rules, CMS added a DPP asynchronous virtual delivery option. And the pay structure is fee-based and value-based. The number of G-codes has been reduced from 15 to 6. There is one G-code for in-person attendance, and one G-code for virtual attendance.

The new reimbursement amount for an in-person or virtual attendance will is $25. There is a G-code for a 5% weight loss, with a reimbursement payment of $145. When an MDPP participant attends all 22 sessions, the MDPP provider will receive a payment of $550.00. When an MDPP participant attends all 22 sessions and reaches all weight loss milestones, the provider will receive $768.00.

There were changes to the proposals, but because of criticism, lessons learned during the PHE, and the desire to prevent or delay type 2 diabetes for Medicare beneficiaries, CMS made the above changes to the MDPP.

The American Medical Association has been endorsing and promoting the National DPP for some time. And if you are interested in determining what might be your cost to deliver the National DPP or the MDPP, you can use the Budget Tool that the AMA offers. 

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