8National Ribat University

Faculty of Graduate Studies & Scientific Research

The Effects of an Educational Program on Using Dietary

Approach to Reduce High Blood Pressure

in Khartoum State , Sudan (2015)

Research Presented to a Ph.D in Medical and Surgical Nursing

Prepared By: Ibrahim Abbakr Ibrahim Abbakr

Supervisor: Prof. Abdel Ghaffar Ali Adam

July 2016

1
 ‫بسم هللا الرحمن الرحيم‬
‫قال هللا تعالى‪:‬‬
‫َ‬ ‫ُ‬ ‫ّ ُ َ َ َ َّ ُ َ ْ َ ُّ ْ َ ُّ ُ َ َ ْ ُ ُ ُ َ ٌ َ َ َ ْ ٌ َّ‬
‫( الله ال ِإله ِإال هو الحي القيوم ال تأخذه ِسنة وال نوم له ما ِفي‬
‫َ‬
‫األ ْ ض َمن َذا َّالذي َي ْش َف ُع ع ْن َد ُه إ َّال بإ ْذنه َي ْع َل ُم َما َب ْينَ‬ ‫ات َو َ‬ ‫الس َم َ‬
‫َّ‬
‫ِ ِ ِِ ِ ِ‬ ‫ِ‬ ‫ِ‬ ‫ر‬ ‫ي‬ ‫ف‬‫ِ‬ ‫ا‬‫م‬ ‫ِ‬ ‫او‬
‫َ‬ ‫َّ َ َ‬ ‫َْ ْ َ َ َ ْ َ ُ ْ َ َ ُ ُ َ َ ْ ّ ْ ْ‬
‫أي ِد ِيهم وما خلفهم وال ي ِحيطون ِبش ي ٍء ِمن ِعل ِم ِه ِإال ِبما شاء و ِسع‬
‫ُ‬ ‫َ‬ ‫ُ ْ ُّ ُ َّ َ َ َ َ ْ َ َ َ َ ُ ُ ُ ْ ُ ُ َ َ ُ َ ْ َ ُّ ْ‬
‫ات واألرض وال يؤوده ِحفظهما وهو الع ِلي الع ِظيم )‬ ‫كر ِس ُّيه السماو ِ‬
‫صدق هللا العظيم‬

‫سورة البقرة االيه (‪.)255‬‬

‫‪2‬‬
 Dedication
This study is dedicated to those who provided me with motivation and

support.

To my supervisor professor ABDEL GHAFFAR ALI ADAM who is first

line of support.

Also I dedicate this study to my wonderful wife Hanan, and my lovely

son Mohammed, brothers and my beautiful sisters.

To everybody tolerated and encouraged the demands of my career and

the time spent on my study.

To my all friends now, past, and future who are hope for nursing future.

To my parent who are my joy and inspiration.

3
 Acknowledgement

I would like to thank the people who have supported and helped me get

to where I am.

Firstly I would like to extend my warmest appreciation and sincerity to

my supervisor professor / Abdel Ghaffar who has kindly provided me

time ,valuable suggestions ,guidance, corrections, comments and support .

I would like to thank the hypertensive patients who participated in this

study and without their help I would not have been able to do this

study.

Also I would like to express my deepest gratitude to my colleagues in the

different hospitals who facilitated resources for me during data collection.

Great thank to my wife for her patience , support and help in data

arrangement that allowed me to be able to pull resources together for

this study.

I
 Abstract

Background: Sudan is considered one of the leading countries in Africa for the
prevalence of hypertension. However, a proper national registry on hypertension is
not available in Sudan and evaluation studies are rarely done. Nevertheless, a
recent study showed an increase in incidences of hypertension in Sudan.

The DASH (Dietary Approaches to Stop Hypertension) diet, which is rich in fruits,
vegetables, and low-fat dairy foods, significantly lowers the blood pressure

Objective: To examine the effectiveness of dietary approach to reduce

hypertension (DASH) in reduction of high blood pressure among hypertensive
patients.

Design: This research is an interventional case control community base study

which was carried in 100 patients; 69 of them females and 31 males whom were
selected by convenient sampling method. They were divided into two groups by
simple random sampling 50 patients assigned in the case group and 50 in control
group then followed every one separately for ten months.

Intervention: The case group were taught individually about dietary approach to
reduce hypertension DASH and each participant in case group possessed a book
for teaching program to eat food low in saturated fat, cholesterol, total fat and
emphasizes fruits, vegetables, and fat-free or low-fat milk and milk products; then
blood pressure measured monthly for both case and control group for ten month.

Result: The study shows decreasing in systolic blood pressure among patients who
followed dietary approach and received teaching significantly in 4th month (p=
0.032) and diastolic blood pressure became significantly in 6 th month (p=0.032)
and became more significant in next four months without change in control group.

Conclusion: The study concluded that a diet rich in fruits, vegetables, and low-fat
dairy foods, reduced saturated and total fat can substantially lower blood pressure.

Recommendation: It is necessary to apply a nutritional approach among all

hypertensive patients because it could minimize both the health care workload and
the money cost for therapy in clinical area.

II
 ‫الخ ـ ـ ــالصة‬

‫خلفية الدراسة‪ :‬يعتبر السودان من الدول البارزة افريقيا في نسبة ارتفاع ضغط الدم ومع ذلك اليوجد سجل وطني‬
‫سليم لتسجيل الحاالت املرضية ُّونادرُّا ما يتم إجراء دراسات تقيمية ملعرفة العدد الحقيقي ملرى الغغط وهناك‬
‫دراسة حديثة تشير الي تزايد ارتفاع حاالت ضغط الدم في السودان ُّ‬

‫الهدف ‪ :‬أجريت هذة الدراسة الختبار مدي فعالية استخدام نظام غذائي غني بالفواكة والخغروات لتقليل ضغط الدم‬
‫لدى مصابي ضعط الدم ‪ُّ .‬‬

‫التصميم‪ :‬هذة الدراسة هي تدخلية ملجموعة الحالة ومجموعة املقارنة معتمدة علي املجتمع ‪ ،‬تمت إجراءها في ‪100‬‬
‫مصاب بمرض ضغط الدم من بينهم ‪ 69‬إمراة و‪ 31‬رجل دون مراعاة اعمارهم وتم تقسيم العدد عن طريق موافقة‬
‫الي مجموعتين عن طريق العينة العشوائية (العدلية) البسيطة ‪ 50‬منهم يمثلون العينة التدخلية حيث‬ ‫املرى‬
‫يستخدمون أدوية ضغط الدم وحمية داش الغذائية و ‪ 50‬منهم يمثلون عينة التحكم ويستخدمون االدوية فقط ومن‬
‫ثم تمت متابعتهم ملدة عشر ة اشهر و قياس ضغط الدم للمجموعتين‪ُّ .‬‬

‫التدخل‪ :‬كل فرد من افراد مجموعة الحالة ُدرس منفردا عن حمية داش الغذائية لتقليل ضغط الدم ُوملك كتاباُّ يحثة‬
‫علي تناول كميات منخفغة من الدهون املشبعة والكوليسترول والدهون الكلية وتشجيع علي زيادة حصة الفواكة‬
‫والخغروات وااللبان قليلة او منزوعة الدسم‪ .‬ثم قياس ضغط الدم للمجموعتين شهريا ملدة عشرة اشهر‪ُّ .‬‬

‫النتائج‪ :‬اظهرت الدراسة بان مستخدمي حمية داش الغذاية لتقليل ضغط الدم مع أالدوية انخفض ضغط الدم‬
‫االنقباى ي لديهم في الشهر الرابع (القيمة االحتمالية = ‪ ) 0.032‬والغغط االبساطي انخفض لديهم عند الشهر السادس‬
‫(القيمة االحتمالية = ‪ )0.032‬دون حدوث تغيير في مجموعة املقارنة‪ُّ .‬‬

‫الخالصة‪ :‬خلصت الدراسة الي أن اتباع نظام (داش) وهو نظام غذائي غني بالفواكة والخغروات ومنتجات االلبان قليلة‬
‫الدسم وتقليل اجمالي الدهون و الدهون املشبعة يؤدي الي تقليل ملحوظ في ضغط الدم‪ُّ .‬‬

‫التوصية‪ :‬من الغروري اتباع نهج تغذية حمية داش الغذائية لكل مرى ارتفاع ضغط الدم النة يقلل من عبء الرعاية‬

‫الصحية ويقلل من التكاليف املالية العالجية للدولة واملريض‪.‬‬

‫‪III‬‬
 Contents

Topic page
‫االية‬
Dedication
Acknowledgement I
Abstract in English II
Abstract in Arabic III
Contents IV
List of Tables VII
List of Figures IX
List of abbreviations X

CHAPTER ONE
Introduction 1
Background 1
Statement of problem 3
Justification 5
Research question 5
Objectives 6
CHAPTER TWO
Literature review 7
Pathophysiology of hypertension 8
Genetics 9
Autonomic nervous system 10
Renin-angiotensin-aldosterone system 11
Endothelial dysfunction 12

IV
Prevention of hypertension 13
Primary prevention of hypertension 14
Management of hypertension 14
Diuretics 14
Adrenergic blockers 16
Calcium channel blockers 17
Direct vascular dilators 17
Central adrenergic agonists 18
Lifestyle modifications 19
Dietary approach to stop hypertension (DASH) 20
Components of DASH eating plan 20
Previous DASH studies 20
DASH, Potassium and high blood pressure 24
DASH, magnesium and blood pressure 26
What to eat in DASH diet 27
CHAPTER THREE
Methodology 33
Study design 33
Study area 33
Study population 35
Sample size and sample procedure 35
Inclusion criteria 38
Exclusion criteria 38
Intervention 38
Methods of data collection 39
Data analysis 39

V
Ethical clearance 40
CHAPTER FOUR
Results 40
CHAPTER FIVE
Discussion 54
CHAPTER SIX
Conclusions and recommendation 58
Conclusions 58
Recommendations 59
References 60
Questionnaire Annex I
DASH book Annex II
Khartoum state hospitals Annex III
Case follow up sheet Annex IV
Control follow up sheet Annex V

VI
 List of tables

TABLE NO TABLE TITLE PAGE

(4.1.1) Gender of population under study 40

(4.1.2) Age study population 40
(4.1.3) Occupation of study population 41
(4.1.4) The income of population under study. 41
(4.1.5) Do you have special doctor 42
(4.1.6) Medical problems 42
(4.1.7) Type of other medical problems 42
(4.1.8) Strategies to control hypertension 43
(4.1.9) Frequency of blood pressure check 43
(4.1.10) Use of antihypertensive medication. 44
(4.1.11) Number of antihypertension medication 44
(4.1.12) Regulatory of an antihypertensive drug 45
(4.1.13) The base line blood pressure 45
(4.1.14) the base line BP * patient antihypertension medication 46
(4.1.15) the symptoms related to high blood pressure 46
(4.1.16) Type of diet follow 47
(4.17) The Amount of salt consumed \ day 47
(4.1.18) p physical activity 48
(4.1.19) Type of physical activity you practice 48
(4.1.20) The Frequency of activities \ week 48
(4.1.21) The common daily food 49
(4.1.22) Awareness of study population about DASH 49
(4.2.1) Differences in systolic blood pressure between cases 50
(intervention group) and control group

VII
(4.2.2) Differences in diastolic blood pressure between cases 52
(intervention group) and control group

VIII
 List of Figures

FIGURE NO FIGURE TITLE page

(3.1) Khartoum state map 34
(3.2) Population under study 37

IX
 Abbreviations

ACE Angiotensin Converting Enzyme

BP Blood Pressure

DALYS Disability Adjusted Life Years

DASH Dietary Approach to Stop Hypertension

DSP Diastolic Blood Pressure

HDL High-Density Lipoproteins

HTN Hypertension

LDL Low-Density Lipoproteins

NO Nitric Oxide

RAS Renin-Angiotensin System

ROS Reactive Oxygen Species

SBP Systolic Blood Pressure

X
Introduction
 1-INTRODUCTION
1.1 BACKGROUND
Blood pressure can be unhealthy even if it stays only slightly above the
normal level of 120/80 mmHg. High blood pressure affects about 50 million or 1 in
4 adult Americans. High blood pressure is especially common among African
Americans who tend to develop it at an earlier age and more often than Whites. It
is also common among older Americans—individuals with normal blood pressure
at age 55 have a 90 percent lifetime risk for developing hypertension. (1)
Worldwide, raised blood pressure is estimated to cause 7.5 million deaths, about
12.8% of the total of all deaths. This accounts for 57 million disability adjusted life
years (DALYS) or 3.7% of total DALYS(2). Raised blood pressure is a major risk
factor for coronary heart disease and ischemic as well as hemorrhagic stroke.
Blood pressure levels have been shown to be positively and continuously related to
the risk for stroke and coronary heart disease(2). In some age groups, the risk of
cardiovascular disease doubles for each increment of 20/10 mmHg of blood
pressure, starting as low as 115/75 mmHg. In addition to coronary heart diseases
and stroke, complications of raised blood pressure include heart failure, peripheral
vascular disease, renal impairment, retinal hemorrhage and visual impairment.
Treating systolic blood pressure and diastolic blood pressure until they are less
than 140/90 mmHg is associated with a reduction in cardiovascular complications.
(2) .

As of 2000, nearly one billion people or ~26% of the adult population of the world
had hypertension. It was common in both developed (333 million) and
undeveloped (639 million) countries[3] . However rates vary markedly in different
regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as
high as 68.9% (men) and 72.5% (women) in Poland.[4]. In Europe hypertension
occurs in about 30-45% of people as of 2013[5]. In 1995 it was estimated that 43

1
million people in the United States had hypertension or were taking
antihypertensive medication, almost 24% of the adult United States population.[6].
The prevalence of hypertension in the United States is increasing and reached 29%
in 2004.[7] . As of 2006 hypertension affects 76 million US adults (34% of the
population) and African American adults have among the highest rates of
hypertension in the world at 44%.[8] . It is more common in blacks, Filipinos, and
Native Americans and less in whites and Mexican Americans, Rates increase with
age, and is greater in the southeastern United States.(10) Hypertension is more
common in men (though menopause tends to decrease this difference) and in those
of low socioeconomic status.[9] .

Although hypertension remains more prevalent in economically developed

countries (37.3%) compared to developing nations (22.9%), it is a much bigger
problem in developing countries, in terms of actual numbers, awareness, treatment
and complications, prevalence is also rising more rapidly across developing
countries where it is estimated that three quarters (1.17 billion) of cases will exist
[10].
by 2025 Recent studies from African countries have shown prevalence to be
15-50%, and higher in urban than in rural populations [11] .

In Khartoum 1990 estimated prevalence was found to be 7.5%, with a positive

correlation between blood pressure and age, weight, body mass index and duration
of urban residence [12] .
More recently, data from the Sudan Household Survey in 2006 of chronic disease
risk factors in Khartoum found hypertension prevalence to be 20.1% and 20.4%
[13]
respectively .Of concern are the poor rates of knowledge and control of
hypertension in sub-Saharan Africa. A systematic review of 25 studies across the
region found that less than 40% of people knew they were hypertensive, less than

2
30% were on treatment and less than 20% of those on treatment had a controlled
blood pressure [14].
In Kassala, Eastern Sudan, knowledge of hypertension was poor, compliance with
anti-hypertensive drug treatment was 59%, and 36.8% said they could not afford to
[15]
buy the drugs they were prescribed . A recent article in the Sudan Tribune
warned that rising levels of non-communicable diseases and an ageing population
will have major implications for health and socio-economic development in the
world’s newest nation [16].
According to the latest WHO data published in April 2011 Hypertension Deaths in
Sudan reached 12,281 or 3.33% of total deaths. The age adjusted Death Rate was
67.67 per 100,000 of population ranks Sudan number 17 in the world. (17).
This study aimed to use another method to reduce high blood pressure
(hypertension ) which is known as dietary approach to stop hypertension (DASH)
in order to decrease prevalence of hypertension . The DASH eating plan is rich in
fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish,
poultry, beans, seeds, and nuts. It also contains less salt and sodium; sweets, added
sugars, and sugar-containing beverages; fats; and red meats. This heart healthy way
of eating is also lower in saturated fat, trans fat, and cholesterol and rich in
nutrients that are associated with lowering blood pressure—mainly potassium,
magnesium, and calcium, protein, and fiber.(18) .

1.2. Statement of the problem:

The mortality due to hypertension (HTN) account for 20%–50% of all

deaths and the projected number of adults who will have hypertension by 2025 is
1.56 billion, it was reported that the highest prevalence of HTN was in Africa and
approximately 80% of deaths in low-middle income countries were due to
commonest complication of HTN is cardiovascular disease. All published studies

3
about hypertension in Sudan targeted small scale studies for different specific
population, a study in some referral clinics in Khartoum had shown cardiac,
neurological and renal symptoms were the major presenting complaints.(64)
Hypertension was detected in 18.2% of population with different occupations in
Khartoum State and 10.2%were known hypertensive. School based study in
Khartoum State has shown 4.9% of obese primary school children in age group 6-
12 years were hypertensive. Passive screening program in Northern state in Sudan
has shown 28.5% of village inhabitants were known hypertensive and 39.6% were
having hypertension after screening. Local studies were conducted in urban
settings rather than rural and showed high prevalence of target organ damages and
almost no data was available from rural areas in states (64)
A study was conducted into blood pressure in a sample of 510 urban Sudanese
working in the post office in Khartoum(19). The mean age was 35 years and 65% of
the workers came from Northern Sudan(19). Cigarette smoking and consumption of
alcohol were commonest amongst those from Southern Sudan. Both systolic and
diastolic BPs rose with age. The prevalence of hypertension (140/90 mmHg or
greater) was 7.5%. BP levels in this study were lower than those reported in
Nigerians or blacks in the Caribbean or the United States (19). There was a
significant positive correlation between systolic blood pressure and diastolic blood
pressure and age, weight, body mass index and duration of residence in the city.
These data confirm that hypertension is becoming an important health problem in
the Sudan.(19)

In 2010, about 58.6 million persons or 25.1 percent of adults age 18 and older
were treated for hypertension. Direct medical spending to treat hypertension
totaled $42.9 billion in 2010, with almost half ($20.4 billion) in the form of
prescription medications. Annual expenditures for those treated for hypertension

4
averaged $733 per adult in 2010 (Agency for Healthcare and Research Quality
April 2013)

1.3. Justification:

o In spite of availability of the hypertension treatment, the incidence and

mortality rate of hypertension is rising up according to many studies.
o Hypertension medications is very costive in comparing with life style
changes (DASH).
o Dietary approach to reduce hypertension (DASH) is a cheap and available
rather than clinical management.
o This means that the drug alone is not enough to control and prevent
complications of the hypertension. So orientations of the patient about
additional method of control blood pressure like dietary approaches to
reduce hypertension DASH is more necessary to be applied.
o No previous study was done

1.4. Research question:

This study sets out to answer the following question:

Can dietary approach and education program contribute to reduction of high blood
pressure?

5
1.5. Objectives:

1.5.1. General objective

To study the effectiveness of an educational program of using dietary

approach to reduce high blood pressure among hypertensive patients in Khartoum
state.

1.5.2. Specific objectives:

1.5.2.1. To apply dietary approach and an educational program for hypertensive

patient in the study group.

1.5.2.2. To assess knowledge of hypertensive patients towards management of

hypertension before intervention.

1.5.2.3\To compare the control of BP among patients using anti hypertensive drugs
plus dietary approach with those using anti hypertensive drugs alone.

6
Literature review
 2. Literature review

Hypertension (HTN) or high blood pressure, sometimes called arterial

hypertension, is a chronic medical condition in which the blood pressure in the
arteries is elevated. Blood pressure is summarized by two measurements, systolic
and diastolic, which depend on whether the heart muscle is contracting (systole) or
relaxed between beats (diastole). This equals the maximum and minimum pressure,
respectively. Normal blood pressure at rest is within the range of 100–140mmHg
systolic (top reading) and 60–90mmHg diastolic (bottom reading). High blood
pressure is said to be present if it is often at or above 140/90 mmHg. Hypertension
is classified as either primary (essential) hypertension or secondary hypertension;
about 90–95% of cases are categorized as "primary hypertension" which means
high blood pressure with no obvious underlying medical cause.[20] .

The remaining 5–10% of cases (secondary hypertension) are caused by

other conditions that affect the kidneys, arteries, heart or endocrine system.
Hypertension puts strain on the heart, leading to hypertensive heart disease and
coronary artery disease if not treated. Hypertension is also a major risk factor for
stroke, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial disease
and is a cause of chronic kidney disease. A moderately high arterial blood pressure
is associated with a shortened life expectancy while mild elevation is not. Dietary
and lifestyle changes can improve blood pressure control and decrease the risk of
health complications, although drug treatment is still often necessary in people for
whom lifestyle changes are not enough or not effective(21) .

Hypertension is rarely accompanied by any symptoms, and its identification is

usually through screening, or when seeking healthcare for an unrelated problem. A
proportion of people with high blood pressure report headaches (particularly at the
7
back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus
(buzzing or hissing in the ears), altered vision or fainting episodes.[21]. These
symptoms, however, might be related to associated anxiety rather than the high
blood pressure itself.[22] .

On physical examination, hypertension may be suspected on the basis of the

presence of hypertensive retinopathy detected by examination of the optic fundus
found in the back of the eye using ophthalmoscopy. Classically, the severity of the
hypertensive retinopathy changes is graded from grade I–IV, although the milder
types may be difficult to distinguish from each other.[23]. Ophthalmoscopy findings
may also give some indication as to how long a person has been hypertensive.[21] .

2.1. Pathophysiology of hypertension

The pathophysiology of hypertension is an area of active research, attempting to

explain causes of hypertension, which is a chronic disease characterized by
elevation of blood pressure. Hypertension can be classified as either essential or
secondary. Essential hypertension indicates that no specific medical cause can be
found to explain a patient's condition. About 90-95% of hypertension is essential
hypertension.[20] .

Secondary hypertension indicates that the high blood pressure is a result of another
underlying condition, such as kidney disease or tumours (adrenal adenoma or
pheochromocytoma). Persistent hypertension is one of the risk factors for strokes,
heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic
renal failure.[24] .

Most mechanisms leading to secondary hypertension are well understood. The

pathophysiology of essential hypertension remains an area of active research, with

8
many theories and different links to many risk factors. Cardiac output and
peripheral resistance are the two determinants of arterial pressure. Cardiac output
is determined by stroke volume and heart rate; stroke volume is related to
myocardial contractility and to the size of the vascular compartment. Peripheral
resistance is determined by functional and anatomic changes in small arteries and
arterioles [25] .

2.2. Genetics

Evidence for genetic influence on blood pressure comes from various

sources.There is greater similarity in blood pressure within families than between
families, which indicates a form of inheritance.[26]. And it was proved that this
finding wasn't due to shared environmental factors.[27]. Single gene mutations are
proved to cause Mendelian forms of high and low blood pressure.[28]. Almost 10
genes have been identified to cause these forms of hypertension.[30] These
mutations affect blood pressure by altering renal salt handling.[29]. Recently and
with the aid of newly developed genetic analysis techniques researchers found
statistically significant linkage of blood pressure to several chromosomal regions,
including regions linked to familial combined hyperlipidemia.[30]. These findings
suggest that there are many genetic loci, each with small effects on blood pressure
in the general population. Overall, however, identifiable single-gene causes of
hypertension are uncommon, consistent with a multifactorial cause of essential
hypertension.(24).

The best studied monogenic cause of hypertension is the Liddle syndrome, a rare
but clinically important disorder in which constitutive activation of the epithelial
sodium channel predisposes to severe, treatment-resistant hypertension.[31].
Epithelial sodium channel activation resulting in inappropriate sodium retention at

9
the renal collecting duct level. Patients with the Liddle syndrome typically present
with volume-dependent, low renin, and low aldosterone, and hypertension.
Screenings of general hypertensive populations indicate that the Liddle syndrome
is rare and does not contribute substantially to the development of hypertension in
the general population.[32]

2.3. Autonomic nervous system

The autonomic nervous system plays a central role in maintaining cardiovascular

homeostasis via pressure, volume, and chemoreceptor signals. It does this by
modifying peripheral vasculature and the function of the kidneys, which affect
cardiac output, vascular resistance, and fluid retention. Problems with this system,
such as excess activity of the sympathetic nervous system, increase blood pressure
and contribute to hypertension.[33]. In addition, increased activity of the
sympathetic accompanied by reduced activity of the parasympathetic has been
associated with many metabolic and hemodynamic abnormalities that result in
increased cardiovascular morbidity and mortality. [34)

The mechanisms of increased sympathetic nervous system activity in hypertension

are complex and involve alterations in baroreflex and chemoreflex pathways at
both peripheral and central levels. Arterial baroreceptors are reset to a higher
pressure in hypertensive patients, and this peripheral resetting reverts to normal
when arterial pressure is normalized. [35] . Furthermore, there is central resetting of
the aortic baroreflex in hypertensive patients, resulting in suppression of
sympathetic inhibition after activation of aortic baroreceptor nerves. This
baroreflex resetting seems to be mediated, at least partly, by a central action of
angiotensin II. [36]. Additional small-molecule mediators that suppress baroreceptor
activity and contribute to exaggerated sympathetic drive in hypertension include

10
reactive oxygen species and endothelin.[37] . Some studies shown that hypertensive
patients manifest greater vasoconstrictor responses to infused norepinephrine than
normotensive controls.[38] . And that hypertensive patients do not show the normal
response to increased circulating norepinephrine levels which generally induces
downregulation of noradrenergic receptor, and its believed that this abnormal
response is genetically inherited.[39] .

Exposure to stress increases sympathetic outflow, and repeated stress-induced

vasoconstriction may result in vascular hypertrophy, leading to progressive
increases in peripheral resistance and blood pressure.(24). This could partly explain
the greater incidence of hypertension in lower socioeconomic groups, since they
must endure greater levels of stress associated with daily living. Persons with a
family history of hypertension manifest augmented vasoconstrictor and
sympathetic responses to laboratory stressors, such as cold pressor testing and
mental stress, that may predispose them to hypertension. This is particularly true of
young African Americans. Exaggerated stress responses may contribute to the
increased incidence of hypertension in this group.(40) .

2.4. Renin-angiotensin-aldosterone system

Another system maintaining the extracellular fluid volume, peripheral resistance

and that if disturbed may lead to hypertension, is the renin-angiotensin-aldosterone
system. Renin is a circulating enzyme that participates in maintaining extracellular
volume, and arterial vasoconstriction, Thus it contributing to regulation of the
blood pressure, it performs this function through breaking down (hydrolyzes)
angiotensinogen secreted from the liver into the peptide angiotensin I, Angiotensin
I is further cleaved by an enzyme that is located primarily but not exclusively in
the pulmonary circulation bound to endothelium, that enzyme is angiotensin

11
converting enzyme (ACE) producing angiotensin II, the most vasoactive
peptide.(41] . Angiotensin II is a potent constrictor of all blood vessels. It acts on
the musculature of arteries and thereby raises the peripheral resistance, and so
elevates blood pressure. Angiotensin II also acts on the adrenal glands too and
releases Aldosterone, which stimulates the epithelial cells of the kidneys to
increase re-absorption of salt and water leading to raised blood volume and raised
blood pressure. So elevation of renin level in the blood, which is normally in adult
human is 1.98-24.6 ng/L in the upright position.[42] .

Recent studies claim that obesity is a risk factor for hypertension because of
activation of the renin-angiotensin system (RAS) in adipose tissue, [43]. And also
linked renin-angiotensin system with insulin resistance, and claims that anyone can
cause the other.[44]. Local production of angiotensin II in various tissues, including
the blood vessels, heart, adrenals, and brain, is controlled by ACE and other
enzymes, including the serine protease chymase. The activity of local renin–
angiotensin systems and alternative pathways of angiotensin II formation may
make an important contribution to remodeling of resistance vessels and the
development of target organ damage (i.e. left ventricular hypertrophy, congestive
heart failure, atherosclerosis, stroke, end-stage renal disease, myocardial infarction,
and arterial aneurysm) in hypertensive persons.[45] .

2.5. Endothelial dysfunction

The endothelium of blood vessels produces an extensive range of substances that

influence blood flow and, in turn, is affected by changes in the blood and the
pressure of blood flow. For example, local nitric oxide and endothelin, which are
secreted by the endothelium, are the major regulators of vascular tone and blood
pressure. In patients with essential hypertension, the balance between the

12
vasodilators and the vasoconstrictors is upset, which leads to changes in the
endothelium and sets up a “vicious cycle” that contributes to the maintenance of
high blood pressure. In patients with hypertension, endothelial activation and
damage also lead to changes in vascular tone, vascular reactivity, and coagulation
and fibrinolytic pathways. Alterations in endothelial function are a reliable
indicator of target organ damage and atherosclerotic disease, as well as
prognosis.[46] .

Evidence suggests that oxidant stress alters many functions of the endothelium,
including modulation of vasomotor tone. Inactivation of nitric oxide (NO) by
superoxide and other reactive oxygen species (ROS) seems to occur in conditions
such as hypertension[47). Normally nitric oxide is an important regulator and
mediator of numerous processes in the nervous, immune and cardiovascular
systems, including smooth muscle relaxation thus resulting in vasodilation of the
artery and increasing blood flow, suppressor of migration and proliferation of
vascular smooth-muscle cells[24]. It has been suggested that angiotensin II enhances
formation of the oxidant superoxide at concentrations that affect blood pressure
minimally [48] .

Endothelin is a potent vasoactive peptide produced by endothelial cells that has

both vasoconstrictor and vasodilator properties. Circulating endothelin levels are
increased in some hypertensive patients, particularly African Americans and
persons with hypertension.[49] .

2.6. Prevention of hypertension:

Much of the disease burden of high blood pressure is experienced by people who
are not labeled as hypertensive. Consequently, population strategies are required to

13
reduce the consequences of high blood pressure and reduce the need for
antihypertensive drug therapy. Lifestyle changes are recommended to lower blood
pressure, before starting drug therapy. The 2004 British Hypertension Society
guidelines proposed the following lifestyle changes consistent with those outlined
by the US National High BP Education Program in 2002[50] .

2.6.1. Primary prevention of hypertension:

2.6.1.1. Maintain normal body weight for adults (e.g. body mass index 20–
25 kg/m2)

2.6.1.2. Reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium
chloride or <2.4 g of sodium per day)
2.6.1.3. Engage in regular aerobic physical activity such as brisk walking (≥30
min per day, most days of the week)
2.6.1.4. Limit alcohol consumption to no more than 3 units/day in men and no
more than 2 units/day in women
2.6.1.5. consume a diet rich in fruit and vegetables (e.g. at least five portions per
day) more detailed later in this chapter

Effective lifestyle modification may lower blood pressure as much an individual

antihypertensive drug. Combinations of two or more lifestyle modifications can
achieve even better results.[51]

2.7. Management of hypertension:

2.7.1. Diuretics

Diuretics are the first-line therapy for hypertension. When a diuretic alone
can’t control the condition, a prescriber adds one or more other types of

14
antihypertensives until the blood pressure is under control. Diuretics work by
eliminating excess salt and water from the body, thus decreasing the pressure from
fluid on the vessel walls. (52) .

2.7.1.1. Nursing considerations during diuretic therapy

 Diuretics can increase serum glucose and cholesterol levels, so monitor

patients with diabetes or high cholesterol levels.
 Teach patients to take diuretics in the morning to avoid nocturnal dieresis
and frequent nocturnal urination.
 Caution patients to stand up slowly to minimize the risk of dizziness from
orthostatic hypotension.
 If your patient is taking a thiazide diuretic or loop diuretic, monitor him for
signs of hypokalemia, such as muscle weakness and changes in mental
status, including confusion and irritability.
 Patients taking a potassium-sparing diuretic, such as triamterene or the
aldosterone antagonist spironolactone, are at risk for hyperkalemia. The risk
is especially high in patients also taking an angiotensin-converting enzyme
(ACE) inhibitor.
 Weigh patients daily at the same time using the same scale. Report a
significant weight gain, such as 3 pounds in 3 days.
 Remind your patient that even if he feels fine, he should keep appointments
with the healthcare provider because renal function must be monitored.(52)

15
2.7.2. Adrenergic blockers

Adrenergic blockers interfere with the sympathetic nervous system

hormones that produce the fight-or-flight response, a response that increases blood
flow to the heart, lungs, skeletal muscles, and brain. (52)

2.7.2.1. Nursing considerations for beta-blocker therapy

 Teach patients that they shouldn’t suddenly stop therapy. Because of the risk
of rebound tachycardia and hypertension, a healthcare provider should
monitor the cessation of beta-blocker therapy.
 Beta blockers can cause transient increases in serum lipid and glucose levels.
 Because beta blockers inhibit the sympathetic nervous system response, they
also hide the symptoms of hypoglycemia and can be dangerous in patients
with diabetes who use insulin.
 Some older beta blockers such as propranolol and high doses of beta1
blockers can block the beta2 receptors in the pulmonary vasculature,
resulting in bronchoconstriction and asthma symptoms.
 Carefully assess patients with asthma or chronic lung disease for an
exacerbation of their symptoms during beta-blocker therapy.
 Check for common adverse effects of beta blockers, such as dizziness,
slowing of the pulse, fatigue, and hypotension.

For alpha-blocker therapy

 Warn patients about the risk of orthostatic hypotension, which can cause
falls.

16
  Teach patients to take their first dose at bedtime and to move slowly from a
sitting to a standing position.(52).

2.7.3. Calcium channel blockers

The two types of calcium channel blockers are dihydropyridines and

nondihydropyridines. Dihydropyridines, such as amlodipine and nifedipine, cause
vasodilation of the peripheral blood vessels and the coronary arteries but no
reduction in heart rate. Nondihydropyridines, such as diltiazem and verapamil,
block the slow calcium channels in the heart and reduce heart rate and cardiac
output, thus reducing blood pressure(52) .

2.7.3.1. Nursing considerations for calcium channel blockers

o Tell patients to report dizziness and symptoms of an irregular heart

rate.
o Teach your patients to avoid grapefruit juice because it inhibits the
hepatic metabolism of calcium channel blockers and may lead to
increased blood drug levels and increased pharmacologic effects.
o All calcium channel blockers should be used cautiously in patients
with heart failure.
o Drugs that inhibit cytochrome P450 isoenzymes, such as
erythromycin, inhibit the metabolism of amlodipine and may result in
a stronger antihypertensive effect.

2.7.4. Direct vascular dilators

Direct vascular dilators, such as hydralazine and minoxidil, relax the smooth
muscle in the arterial walls. Because they don’t improve cardiovascular health and

17
may produce certain adverse effects, they aren’t recommended as first-line drugs.
Usually, they are added to the regimen when patients are resistant to diuretics,
calcium channel blockers, and beta blockers. (52) .

Research has shown that patients need information about several medication-
related topics, no matter what the medication. A well-informed patient and/or
family can help prevent medication errors by hospital staff and is less likely to
make medication errors at home. Adherence to the medication regimen is another
goal achieved through patient education. Before beginning any teaching, however,
always assess the patient’s current knowledge by asking if he or she is familiar
with the medication, how it is taken at home, what precautions or follow-up care is
required, and other questions specific to each drug. Based on the patient’s current
knowledge level and taking into consideration factors such as readiness to learn,
environmental and social barriers to learning or adherence, and cultural factors.(53).

2.7.4.1. Nursing considerations for direct vascular dilators

 Hydralazine may cause a lupuslike syndrome, which is reversible when

hydralazine therapy is discontinued.
 Minoxidil can produce hair growth on the face, arms, back, and chest, which
may cause patients, especially women, distress. Assure patients that hair
growth reverses when minoxidil therapy stops (52).

2.7.5. Central adrenergic agonists

Central adrenergic agonists, such as clonidine and methyldopa, stimulate the

alpha2-adrenergic receptors in the central nervous system and decrease blood
pressure by decreasing sympathetic activity. The drugs’ effects include reduced
heart rate and cardiac output and increased peripheral vasodilation. These drugs

18
aren’t usually recommended as first-line therapy, though methyldopa may be used
as a first-line drug in pregnant women because of its safety profile.

2.7.5.1. Nursing considerations for Central adrenergic agonists

 Central adrenergic agonists pose a higher risk of orthostatic hypotension, so

tell patients to be careful when rising to a standing position.
 Explain that these drugs may cause depression, sedation, dry mouth,
constipation, urine retention, and blurred vision.
 Tell patients not to stop taking these drugs on their own because an abrupt
withdrawal can result in rebound hypertension.
 Teach patients using transdermal clonidine therapy to apply a new patch
weekly to a clean, hairless area on the upper arm or chest; to change the
patch site every week; to check for erythema or a rash; and to cover the
patch with an adhesive to maintain good skin contact and promote
absorption of the drug.

All above is available management of hypertension but still incidence,

prevalence and complication of hypertension is rising up, so life style change or
modification mainly in eating and daily livening activity must be changed. So the
plan like dietary approach to stop hypertension (DASH) it is necessary to be
established.(52).

2.8. Lifestyle modifications

The first line of treatment for hypertension is identical to the recommended

preventive lifestyle changes and includes dietary changes, physical exercise, and
weight loss. These have all been shown to significantly reduce blood pressure in
people with hypertension their potential effectiveness is similar to using a single

19
medication. If hypertension is high enough to justify immediate use of medications,
lifestyle changes are still recommended in conjunction with medication. Dietary
change such as a low sodium diet is beneficial. A long term (more than 4 weeks)
low sodium diet is effective in reducing blood pressure, both in people with
hypertension and in people with normal blood pressure.[54] .

2.9. Dietary approach to stop hypertension (DASH)

What Is the DASH eating Plan?

Food low in saturated fat, cholesterol, and total fat and that emphasizes fruits,
vegetables, and fat-free or low-fat milk and milk products. This eating plan—
known as the DASH eating plan—also includes whole grain products, fish,
poultry, and nuts. It is reduced in lean red meat, sweets, added sugars, and sugar-
containing beverages compared to the typical American diet. It is rich in
potassium, magnesium, and calcium, as well as protein and fiber.(55)
2.10. Components of DASH eating plan:
The DASH eating plan follows heart healthy guidelines to limit saturated fat and
cholesterol. It focuses on increasing intake of foods rich in nutrients that are
expected to lower blood pressure, mainly minerals (like potassium, calcium, and
magnesium), protein, and fiber. It includes nutrient-rich foods so that it meets other
nutrient requirements as recommended by the Institute of Medicine.(55)
2.11. Previous DASH studies:

2.11.1. The first DASH study done by national institutes of health and national
heart, lung and blood institute department of health and human services in
U.S(united state) involved 459 adults with systolic blood pressures of less than
160 mmHg and diastolic pressures of 80–95 mmHg. About 27 percent of the
participants had high blood pressure. About 50 percent were women and 60

20
percent were African Americans. It compared three eating plans: a plan that
includes foods similar to what many Americans regularly eat; a plan that includes
foods similar to what many Americans regularly eat plus more fruits and
vegetables; and the DASH eating plan. All three plans included about 3,000
milligrams of sodium daily. None of the plans was vegetarian or used specialty
foods. Results were dramatic. Participants who followed both the plan that
included more fruits and vegetables and the DASH eating plan had reduced blood
pressure. But the DASH eating plan had the greatest effect, especially for those
with high blood pressure. Furthermore, the blood pressure reductions came fast
within 2 weeks of starting the plan.(55).
2.11.2. The second DASH done by national institutes of health and national heart,
lung, and blood institute department of health and human services in U.S(united
state) study looked at the effect on blood pressure of a reduced dietary sodium
intake as participants followed either the DASH eating plan or an eating plan
typical of what many Americans consume. This second study involved 412
participants. Participants were randomly assigned to one of the two eating plans
and then followed for a month at each of the three sodium levels. The three sodium
levels were a higher intake of about 3,300 milligrams per day (the level consumed
by many Americans), an intermediate intake of about 2,300 milligrams per day,
and a lower intake of about 1,500 milligrams per day. Results showed that
reducing dietary sodium lowered blood pressure for both eating plans. At each
sodium level, blood pressure was lower on the DASH eating plan than on the other
eating plan. The greatest blood pressure reductions were for the DASH eating plan
at the sodium intake of 1,500 milligrams per day. Those with high blood pressure
saw the greatest reductions, but those with prehypertension also had large
decreases. Together these studies show the importance of lowering sodium intake

21
whatever your eating plan. For a true winning combination, follow the DASH
eating plan and lower your intake of salt and sodium.(55)

2.11.3. Third DASH study done by (Whitt-Glover MC (2013) in North Carolina

neighborhoods this randomized trials have demonstrated the effectiveness of the
(DASH) program for lowering blood pressure; however, program participation has
been limited in some populations. The objective of that pilot study was to test the
feasibility of using a culturally modified version of DASH among African
Americans in an under resourced community. The methods of randomized
controlled pilot study recruited African Americans in 2 North Carolina
neighborhoods who had high blood pressure and used fewer than 3
antihypertension medications. That offered 2 individual and 9 group DASH
sessions to intervention participants and 1 individual session and printed DASH
educational materials to control participants. The results of that 152 potential
participants, 25 were randomly assigned to either the intervention (n = 14) or the
control (n = 11) group; 22 were women, and 21 were educated beyond high school.
At baseline, mean blood pressure was 130/78 mm Hg; 19 participants used
antihypertension medications, and mean body mass index was 35.9 kg/m2.
Intervention participants attended 7 of 9 group sessions on average. After 12
weeks, observed significant increases in fruit and vegetable consumption and
increases in participants’ confidence in their ability to reduce salt and fat
consumption and eat healthier snacks in intervention compared with control
participants. Which found no significant decreases in blood pressure. The
conclusion Implementation of a culturally modified, community-based DASH
intervention was feasible in the small sample of African Americans, which
included people being treated for high blood pressure (56).

22
2.11.4. Fourth study: Done by (Blumenthal JA, Babyak MA 2010) in UN (united
nation) effects of the dash diet alone and in combination with exercise and weight
loss on blood pressure and cardiovascular biomarkers in men and women with high
blood pressure: whish show the following result clinic-measured BP was reduced
by 16.1/9.9 mm hg (dash plus weight management); 11.2/7.5 mmhg (DASH
alone); and 3.4/3.8 mmhg (usual diet controls) (P < .001). A similar pattern was
observed for ambulatory BP (P < .05). Greater improvement was noted for DASH
plus weight management compared with DASH alone for pulse wave velocity,
baroreflex sensitivity, and left ventricular mass (all P < .05). For overweight or
obese persons with above-normal BP, the addition of exercise and weight loss to
the DASH diet resulted in even larger BP reductions, greater improvements in
vascular and autonomic function, and reduced left ventricular mass.(57) .

2.11.5. Study number five DASH, Blood Pressure and Cholesterol: A study of
116 people with borderline high blood pressure found that men and women on the
DASH diet experienced significantly lower blood pressure than those on a control
diet. Blood pressure, which is measured in millimeters of mercury (mmHg),
indicates the pressure blood is exerting on the walls of blood vessels. Systolic
blood pressure dropped 12 mmHg in men and 11 mmHg in women. Diastolic
pressure dropped 6 mmHg in men and 7 mmHg in women during the 6-month trial
period. The research wasn’t as clear when it comes to cholesterol and the DASH
diet. Cholesterol lab results typically are reported as two numbers: HDL (high-
density lipoproteins) and LDL (low-density lipoproteins). HDL is considered
“good cholesterol” and clears extra cholesterol from the blood vessels, whereas
LDL, "bad cholesterol," deposits cholesterol in the blood vessels. Cholesterol is
measured in milligrams per deciliter, or mg/dL. The result of study of 436 people
found that the DASH diet significantly affected cholesterol levels(60).

23
2.11.6. Study number six DASH and potassium: done by Mike adams
(November-06-2009) to evaluate the effectiveness of oral potassium on blood
pressure meta-analysis of Randomized Controlled Clinical Trials in United
Kingdom(59)

The results by means of a random-effects model, findings from individual trials

were pooled, after results for each trial were weighted by the inverse of its
variance. An extreme effect of potassium in lowering blood pressure was noted in
1 trial. After exclusion of this trial, potassium supplementation was associated with
a significant reduction in mean (95% confidence interval) systolic and diastolic
blood pressure of-3.11 mm Hg (-1.91 to-4.31 mm Hg) and-1.97 mm Hg (-0.52 to-
3.42 mm Hg), respectively. Effects of treatment appeared to be enhanced in studies
in which participants were concurrently exposed to a high intake of sodium.(59)

Conclusions: Low potassium intake may play an important role in the genesis of
high blood pressure. Increased potassium intake should be considered as a
recommendation for prevention and treatment of hypertension, especially in those
who are unable to reduce their intake of sodium (59)

2.13. DASH, Potassium and high blood pressure

Potassium is a mineral that helps maintain heart function. Foods high in potassium
are often recommended for people taking diuretics- a medication used in the
treatment of high blood pressure. High potassium foods are also loaded with fiber,
vitamins, and minerals, which are beneficial to overall health. High potassium
foods include both fresh fruits and fresh or frozen vegetables. Fruits that top the list
are bananas, kiwi, cantaloupe, peaches, oranges, grapefruit, apricots and dried fruit.
Vegetables high in potassium include spinach and other dark greens, broccoli,

24
tomatoes, white and sweet potatoes and dried beans. Unfortunately, most of us
don't eat enough vegetables in our diet.(58)

The role of potassium in the body crosses over into many physiological events that
include nerve transmission, muscle contraction, enzymatic reactions, carbohydrate
synthesis, basic cell functions, and acid-base balance. Inadequate potassium intake
in the diet might play a role in the development of high blood pressure, stroke, and
cardiovascular disease. In addition to increasing the potassium foods in our diet,
several studies now show that potassium supplementation can reduce blood
pressure. When it comes to lowering blood pressure, potassium packs a powerful
punch. Scientists began studying the effects of potassium on high blood pressure as
early as 1928. Now a major study of 300 nurses shows that potassium can lower
the blood pressure even if it's in the normal range. Good sources of potassium are
dried apricots, avocados, dried figs, acorn squash, baked potatoes, kidney beans,
cantaloupe, citrus fruits, and bananas. You can also buy potassium supplements. If
you're taking a diuretic, the body is getting rid of potassium along with fluid.
Sodium and potassium play related role in controlling fluid balance in the body.
Without sufficient potassium to help the body secrete sodium, sodium builds up
and exerts its harmful effects. Thus, to reduce high blood pressure most people
need not only to lower sodium intake but also to increase potassium consumption.
Indeed, some studies indicate that potassium intake is a stronger factor in
determining blood pressure than is sodium intake. Various population studies
confirm a beneficial effect on blood pressure from increases in potassium
consumption. High potassium foods help lower blood pressure, but potassium
exhibits additional powers to prevent stroke directly regardless of blood pressure,
says University of Minnesota hypertension expert Dr. Louis Tobian, Jr. In tests, he
fed rats that had high blood pressure either a high-potassium diet or a "normal"

25
potassium diet. Forty percent on the "normal" potassium suffered small strokes,
evidenced by bleeding in the brain. No brain hemorrhages occurred in rats on high
potassium. The best way to supplement potassium is with fruit, which contains
more of the mineral than amounts found in potassium supplements. However, fruit
contains so much potassium that people taking "potassium sparing" drugs (as some
hypertensives do) can end up with too much potassium by eating several pieces of
fruit per day. Therefore, people taking potassium-sparing diuretics should consult
the prescribing doctor before increasing fruit intake. The fiber provided by
vegetarian diets may also help reduce high blood pressure. A great amount of
potassium is also lost in heavy sweating. The loss of potassium from the cell will
result in intracellular water loss - dehydration that will become chronic unless
more water and some high potassium-containing foods are added to the daily diet.
Continued pattern of potassium loss from the body will result in excess sodium
retention by the kidneys and the first stages of high blood pressure, raised
cholesterol, heart disease and irregular pulse will ensue. The foods that have high
potassium content are dried fruits like raisins, dried plums, dried apricot and dates
(59)

2.14. DASH, magnesium and blood pressure:

According to the meta-analysis, published in the European Journal of Clinical

Nutrition, taking a magnesium supplement can reduce systolic blood pressure by
three to four points, and diastolic blood pressure by two to three points. While this
change is not large enough to bring a hypertensive patient’s blood pressure back to
normal (normal blood pressure is under 120/80, while hypertension is 140/90 or
higher), the result is still considered clinically significant. Notably, however, the
best results were observed in those taking an average dose of 370 mg of
magnesium citrate per day, which is actually above Health Canada’s tolerable
26
upper intake level of 350 mg per day via supplements. Having said that, the 350
mg ceiling was established because of the potential for diarrhea, a side effect that
can be minimized by gradually increasing supplementation( 65).

These results reinforce previous findings from the DASH (Dietary Approaches to
Stop Hypertension) study, which found that a diet that includes plenty of foods rich
in magnesium, potassium, calcium and fibre can help to control blood pressure,
even without reducing sodium intake (cutting sodium helped make the drop even
more pronounced). Notably, the DASH study examined the effect of food on
blood pressure; the new meta-analysis suggests that taking magnesium in
supplemental form could also be of some benefit (65)

2.15. DASH diet: What to eat

Versions of the DASH diet include lots of whole grains, fruits, vegetables and low
fat dairy products. The DASH diet also includes some fish, poultry and legumes.
You can eat red meat, sweets and fats in small amounts. The DASH diet is low in
saturated fat, cholesterol and total fat. The recommended servings from each food
group for the 2,000-calorie-a-day DASH diet.(66)

Grains: 6 to 8 servings a day

Grains include bread, cereal, rice and pasta. Examples of one serving of grains
include 1 slice whole-wheat bread, 1 ounce (oz.) dry cereal, or 1/2 cup cooked
cereal, rice or pasta.(66)

 Focus on whole grains because they have more fiber and nutrients than do
refined grains. For instance, use brown rice instead of white rice, whole-
wheat pasta instead of regular pasta and whole-grain bread instead of white

27
 bread. Look for products labeled "100 percent whole grain" or "100 percent
whole wheat."
 Grains are naturally low in fat, so avoid spreading on butter or adding cream
and cheese sauces.

Vegetables: 4 to 5 servings a day

Tomatoes, carrots, broccoli, sweet potatoes, greens and other vegetables are full of
fiber, vitamins, and such minerals as potassium and magnesium. Examples of one
serving include 1 cup raw leafy green vegetables or 1/2 cup cut-up raw or cooked
vegetables.(66)

 Don't think of vegetables only as side dishes a hearty blend of vegetables

served over brown rice or whole-wheat noodles can serve as the main dish
for a meal.
 Fresh or frozen vegetables are both good choices. When buying frozen and
canned vegetables, choose those labeled as low sodium or without added
salt.
 To increase the number of servings you fit in daily, be creative. In a stir-fry,
for instance, cut the amount of meat in half and double up on the vegetables.

Fruits: 4 to 5 servings a day many fruits need little preparation to become a

healthy part of a meal or snack. Like vegetables, they're packed with fiber,
potassium and magnesium and are typically low in fat exceptions include avocados
and coconuts. Examples of one serving include 1 medium fruit or 1/2 cup fresh,
frozen or canned fruit or 4 ounces of juice.(66)

 Have a piece of fruit with meals and one as a snack, then round out your day
with a dessert of fresh fruits topped with a splash of low-fat yogurt.

28
  Leave on edible peels whenever possible. The peels of apples, pears and
most fruits with pits add interesting texture to recipes and contain healthy
nutrients and fiber.
 Remember that citrus fruits and juice, such as grapefruit, can interact with
certain medications, so check with your doctor or pharmacist to see if they're
OK for you.
 If you choose canned fruit or juice, make sure no sugar is added.

Dairy: 2 to 3 servings a day

Milk, yogurt, cheese and other dairy products are major sources of calcium,
vitamin D and protein. But the key is to make sure that you choose dairy products
that are low fat or fat-free because otherwise they can be a major source of fat and
most of it is saturated. Examples of one serving include 1 cup skim or 1 percent
milk, 1 cup yogurt, or 1 1/2 oz. cheese.(66)

 Low-fat or fat-free frozen yogurt can help you boost the amount of dairy
products you eat while offering a sweet treat. Add fruit for a healthy twist.
 If you have trouble digesting dairy products, choose lactose-free products or
consider taking an over-the-counter product that contains the enzyme
lactase, which can reduce or prevent the symptoms of lactose intolerance.
 Go easy on regular and even fat-free cheeses because they are typically high
in sodium.

Lean meat, poultry and fish: 6 or fewer servings a day

Meat can be a rich source of protein, B vitamins, iron and zinc. But because even
lean varieties contain fat and cholesterol, don't make them a mainstay of your diet
cut back typical meat portions by one-third or one-half and pile on the vegetables

29
instead. Examples of one serving include 1 oz. cooked skinless poultry, seafood or
lean meat or 1 egg(66).

 Trim away skin and fat from poultry and meat and then bake, broil, grill or
roast instead of frying in fat.
 Eat heart-healthy fish, such as salmon, herring and tuna. These types of fish
are high in omega-3 fatty acids, which can help lower your total cholesterol.

Nuts, seeds and legumes: 4 to 5 servings a week

Almonds, sunflower seeds, kidney beans, peas, lentils and other foods in this
family are good sources of magnesium, potassium and protein. They're also full of
fiber and phytochemicals, which are plant compounds that may protect against
some cancers and cardiovascular disease. Serving sizes are small and are intended
to be consumed weekly because these foods are high in calories. Examples of one
serving include 1/3 cup (1 1/2 oz.) nuts, 2 tablespoons seeds, or 1/2 cup cooked
beans or peas.(66)

 Nuts sometimes get a bad rap because of their fat content, but they contain
healthy types of fat monounsaturated fat and omega-3 fatty acids. They're
high in calories, however, so eat them in moderation. Try adding them to
stir-fries, salads or cereals.
 Soybean-based products, such as tofu and tempeh, can be a good alternative
to meat because they contain all of the amino acids your body needs to make
a complete protein, just like meat.

Fats and oils: 2 to 3 servings a day

Fat helps your body absorb essential vitamins and helps your body's immune
system. But too much fat increases your risk of heart disease, diabetes and obesity.

30
The DASH diet strives for a healthy balance by limiting total fat to 27 percent or
less of daily calories from fat, with a focus on the healthier monounsaturated fats.
Examples of one serving include 1 teaspoon soft margarine, 1 tablespoon
mayonnaise or 2 tablespoons salad dressing.(66)

 Saturated fat and trans fat are the main dietary culprits in raising your blood
cholesterol and increasing your risk of coronary artery disease. DASH helps
keep your daily saturated fat to less than 6 percent of your total calories by
limiting use of meat, butter, cheese, whole milk, cream and eggs in your
diet, along with foods made from lard, solid shortenings, and palm and
coconut oils.
 Avoid trans fat, commonly found in such processed foods as crackers, baked
goods and fried items.
 Read food labels on margarine and salad dressing so that you can choose
those that is lowest in saturated fat and free of trans fat.

Sweets: 5 or fewer a week

You don't have to banish sweets entirely while following the DASH diet just go
easy on them. Examples of one serving include 1 tablespoon sugar, jelly or jam,
1/2 cup sorbet, or 1 cup (8 oz.) lemonade.(66)

 When you eat sweets, choose those that are fat-free or low-fat, such as
sorbets, fruit ices, jelly beans, hard candy, graham crackers or low-fat
cookies.
 Artificial sweeteners such as aspartame (NutraSweet, Equal) and sucralose
(Splenda) may help satisfy your sweet tooth while sparing the sugar. But
remember that you still must use them sensibly. It's OK to swap a diet cola

31
 for a regular cola, but not in place of a more nutritious beverage such as low-
fat milk or even plain water.
 Cut back on added sugar, which has no nutritional value but can pack on
calories.

2.16. DASH diet: Alcohol and caffeine

Drinking too much alcohol can increase blood pressure. The DASH diet
recommends that men limit alcohol to two or fewer drinks a day and women one or
less. The DASH diet doesn't address caffeine consumption. The influence of
caffeine on blood pressure remains unclear. But caffeine can cause your blood
pressure to rise at least temporarily. If you already have high blood pressure or if
you think caffeine is affecting your blood pressure, talk to your doctor about your
caffeine consumption (66) .

32
Methodolog
 3. Methodology

3.1. Study design

The study was an interventional case control community based study. The case
was received antihypertensive drug plus using dietary approach to stop
hypertension (DASH) and the control received only antihypertensive drug.

3.2. Study area

Khartoum is one of Sudan states. Although it is the smallest state in terms of area
(22,142 km2), it is the most populated state (5,274,321 in 2008 census). It contains
the country's largest city in terms of population, Omdurman, and the city of
Khartoum, which is the capital of the state as well as the national capital of Sudan. The

capital city contains offices of the state, governmental and non-governmental

organizations, cultural institutions, and the main airport. (61)

The state lies between longitudes 31.5 to 34 °E and latitudes 15 to 16 °N. It is

surrounded by River Nile State in the north-east, in the north-west by the Northern
State, in the east and southeast by the states of Kassala, Gedaref and Gezira, and in the

west by North Kurdufan(61)

3.2.1. Administrative divisions: The state is geographically divided into blocks

(or clusters), which are further subdivided into localities. There are a total of three
blocks and seven localities. (61)

3.2.2. First block: Jebel Aulia Locality and AL Kharṭoum Locality

33
This starts from the Mogran the confluence of the Blue Nile and White Nile, and
extends southward between them to the boundaries of Gezira state. The block is
characterized by Sundus and Soba agricultural schemes in both the Gebel Aulia
and Khartoum localities, along with a number of livestock, poultry, fishing, and
fodder production projects, as well as vegetable and fruit farms. (61)

3.2.3. Second block: Khartoum North and Sharq an-Nil Locality (Blue Nile)

This is the northern block, between the Blue Nile and the River Nile. The largest
town in this block is Khartoum North. There are many agricultural projects, such
as the Soba East and Seleit projects, and the largest dairy project in the state, the
Kuku village project. The block also includes the largest industrial areas in the
Sudan.

3.2.4. Third block: Omdurman Locality, Ombadda Locality (Um Badda) and
Karari Locality (Karari) (61)

34
Figure NO (3.1): shows the Khartoum state map and location of the main city

Khartoum, Bahri and Omdurman

Health services and socioeconomic status: The Khartoum state populations are
composed of different tribes of Sudan which arrived to it from north, south, east
and western of Sudan and the socioeconomic status is varies from low, moderate
and high. The people in Khartoum are employed in different jobs: governmental
job, labor, free business etc.

The Khartoum state populations receive their medical health services from 48
public health centers which are divided into 16 public hospitals in Khartoum, 19 in
Omdurman and 18 in Khartoum Bahari in addition to private clinics and hospitals.

Note: Khartoum state hospitals are listed and attached as an annex

3.3. Study population

Hypertensive patients hospitalized and none hospitalized (out-patient clinic) and in

the community without hypertension complication.

3.4. Sample size and sample procedure

The total number of participant were 100 hypertensive patients divided into
two groups, 50 persons case and 50 persons as control that is selected by non-
randomized method called convenience sample method.

Convenience sampling or accidental sampling is a type of non-probability

sampling which involves the sample being drawn from that part of the population
which is close to hand it has several advantages like expedited data collection,
ease of research, readily available and cost effective(62).

35
The researcher screened 130 potential participants by direct interview. The study
excluded 30 potential participants via direct intervention, 10 because of significant
heart disease (heart failure and ischemic heart diseases) informed by patients, 9
because of refusal to participate in the study and 11 excluded due to renal disease
(patients told). We obtained verbal consent from 100 potential participants; this
100 patients are divided into two groups 50 eligible men and women were assigned
to be intervention group while 50 patient men and women were assigned to be
control group of the study (50 cases, 50 controls). This was done by simple random
sample.

During study 5 patients dropped from study (3 of them didn’t want to continue
more in the study and loss contact for 2 patients) and 45 patient completed as case
(intervention group). From the control group 7 patients dropped from study due to
loss of contact and 43 patients completed as control group.

36
 130 potential participants investigated

30 was excluded from study

Significant heart disease (n=10)

Refused to participate (n=9)

Kidney disease (n=11)

100 cases are accepted to be

participants in study

50 patients assigned as 50 patients assigned as

control group case group

7 patients dropped from 5 patients dropped from

study study

.loss of contact (n=7) .refuse to continue (n=3)

.loss of contact (n=2)

43 patients continued till

end of study 45 patients continued till
end of study

Figure NO (3.2): Shows the diagram of sample and sample procedure during study period

Note: n= number of the patient

37
3.5. Inclusion criteria:

Any adult patient diagnosed as hypertensive male or female without complications,

who respect and able to apply the plan and mentally sound is eligible to be
included in this study.

3.6. Exclusion criteria

Hypertensive patient child, adult mentally un-cognitive, who have complications

and not able to apply the plan will be excluded from the study.

3.7. Intervention:

Intervention was done as follow: (measurement of blood pressure) potential

participants were asked to refrain from smoking or ingesting caffeine for at least 30
minutes before their appointment time. Measurements were standardized for cuff
size, position, environment, and time of day. After 5 minutes of quiet rest, 4 seated
BP readings, each 2 minutes apart, were obtained using electronic
sphygmomanometer.

The blood pressure was measured at the beginning as baseline date for both cases
and control groups then every month for 10 months to compare the result

The researcher discussed teaching program to be taught to the case group

individually, each participant in case group should possess book for teaching
program, in teaching program each patient was taught individually about DASH to
eat food low in saturated fat, cholesterol, and total fat and emphasis was placed on
fruits, vegetables, and fat-free or low-fat milk and milk products.

Note: The following is attached as annex

 The teaching book about dietary approach to stop hypertension

38
  Follow up sheets for both case and control groups

3.8. Methods of data collection:

The data were collected by using two methods: direct measurement of blood
pressure and self administrated questionnaire.

3.8.1. Self administrated questionnaire

The questionnaire is designed to assess level of knowledge of patients under study

about dietary approach to stop hypertension, life style of patients, follow-up,
strategies follow to maintain blood pressure is acceptable measure, type of diet and
exercise. The questionnaire is attached as annex

The data that collected by questionnaire for both case and control group to know
the baseline information.

3.8.2. The blood pressure was measured at beginning as baseline date for both case
and control group then every month for 10 months to compare the result.

3.9. Data analysis:

The researcher was used Statistical Package for the Social Sciences (SPSS) to
analyze the results.

3.10. Ethical clearance:

All participants have a right to refuse or accept to participate in the study.

 Approval from EL Ribat University was obtained.

 Verbal consent of patients (participants) was obtained.

39
Results
 4. Results
4.1. Result of both group case and control as primary screening without
intervention
The total population under study was 100 patients: 69 were female 35 in
intervention group 34 control group and 31 were male 15 intervention group and
16 control group.

Table (4.1.1): Shows the gender of population under study.

gender Intervention group Control group

Male 15 (30%) 16 (32%)

Female 35 (70%) 34 (68%)

Total 50 (100%) 50 (100%)

(68% ) of intervention group and (72%) of control group were in medial age
between 31 year to 60 years and (28% ) above 60 years while (4%) were 30 years
and less in intervention group.

Table (4.1.2): Shows the age of the study population.

Age group Intervention group Control group

less than 30 year 2 (4% ) 0 (0%)
31-60 year 34 (68%) 36 (72%)
more than 60 year 14 (28%) 14 (28%)
Total 50 (100%) 50 (100%)

40
The most of population included in the study were house wives (32%) in
intervention group and (32%) in control group and (12%) were employee in
control group and (10%) employee in intervention group.

Table (4.1.3): Shows occupation of study population

Occupation Intervention group Control group

Employee 5 (10%) 6 (12%)
labor 4 (8%) 6 (12%)
house wife 16 (32%) 16 (32%)
others 25 (50%) 22 (24%)
Total 50 (100%) 50 (100%)

Table No (4.1.4): Shows that those with income less than 1000 Sudanese pounds
account for (92% ) of the patient under study in intervention and control group.

Table (4.1.4): Shows the income/month of the population under study.

Income/month Intervention group Control group

less than 1000 Sudanese pounds 46 (92%) 46 (92%)

1000-2000 Sudanese pounds 3 (6%) 4 (8%)

more than 2000 Sudanese pounds

1 (2%) 0 (0%)

Total 50 (100%) 50 (100%)

41
(90%) of patients have special doctor in intervention group (86%) in control group
while (10%) and (14%) have no doctor for follow up.

Table (4.1.5): Shows whether the patients have special doctor for follow up

Follow up Intervention group Control group

Have special doctor 45 (90%) 43 (86%)
No special doctor 5 (10%) 7 (14%)
Total 50 (100%) 50 (100%)

(70%) of patients have no other medical problems rather than hypertension in

intervention group and (76%) in control group while (30%) have other medical
problems in addition to hypertension in intervention and (24%) in control but not
consider as hypertension complication.
Table (4.1.6): Shows whether the patients have other medical problems

Other medical problems Intervention group Control group

Yes 15 (30) 12 (24%)
No 35 (70%) 38 (76%)
Total 50 (100% 50 (100%)

Table (4.1.7): Shows types of other medical problems

Medical problems Intervention group Control group
Free from other disease 35 (70%) 38(76%)
Diabetes 5 (10%) 3 (6%)
Asthma 6 (12%) 7 (14%)
Others 4 (8%) 2 (4%)
Total 50 (100%) 50 (100%)

42
(86%) of patients have no specific strategies to reduce their blood pressure in
control group and (84%) in intervention group. The remaining follow tradition
methods to control their blood pressure as in table below.
Table (4.1.8): Shows the strategies used to control hypertension

Strategies Intervention group Control group

Eating style 0 (0%) 0 (0%)
Exercising 5 (10%) 4 (8%)
Reducing stress 3 (6%) 3 (6%)
No strategies 42 (84) 43 (86%)
Total 50 (100%) 50 (100%)

Shows that more than (80%) of patients have monthly follow up for hypertension
which is a good indicator for hypertensive patient to prevent further blood pressure
elevation and so prevent complication
Table (4.1.9): Shows the frequency of blood pressure checkup.

Check up of blood pressure Intervention group Control group

Monthly 40 (80%) 43 (86%)
4 times \ year 3 (6%) 1 (2%)
Irregular follow 7 (14%) 6 (12%)
Total 50 (100%) 50 (100%)

43
100% of patients under study have already used antihypertensive medication.
Table (4.1.10): Shows the use of antihypertensive medication.

Medication Intervention group Control group

Have antihypertensive medication 50 (100%) 50 (100%)
No antihypertensive medication 0 (0%) 0 (0%)
Total 50 (100%) 50 (100%)

(52%) of patients had single antihypertensive medication in intervention group and

(46%) in control group, (32%) of patients have two antihypertensive medications
in control, (28%) had two antihypertensive in intervention group and (20%) were
on three antihypertensive drugs in case and control.
Table (4.1.11): Shows the number of antihypertensive medications used by
patient

Anti HTN drugs Intervention group Control group

Single antihypertension 26 (52%) 23 (46%)
Two antihypertension 14 (28%) 16 (32%)
Three antihypertension 10 (20%) 11 (22%)
Total 50 (100%) 50 (100%)

44
(82% ) of patients have regular intake of medication as advised and (18%) were on
and off medication in intervention group and (80%) regular intake in control group.
Table (4.1.12): Shows the regulatory of using antihypertensive drug
Antihypertensive drugs Intervention group Control group
Regular 41 (82%) 40 (80%)
Irregular 9 (18%) 10 (20%)
Total 50 (100%) 50 (100%)

Most of patients under study had pre-hypertension stage which presented (44%) in
case and (46%) in control group, (30% ) have stage I hypertension in each cases
and control while (16%) were stage II of hypertension in case and (18%) in control
group, (10% ) have 160/100mmHg in case group and (6%) have more than
160/100mmHg in control group.
Table (4.1.13) shows the base line blood pressure of patients under study

Base line blood pressure Intervention group Control group

120-139\80-89 mmhg 22 (44%) 23 (46%)
140-159 \ 90-99 mmhg 15 (30%) 15 (30%)
160 \100 mmhg 8 (16%) 9 (18%)
More than 160 \ 100 mmhg 5 (10%) 3 (6%)
Total 50 (100%) 50 (100%)

45
The relationship between antihypertensive medications and base line blood
pressures. 52% of patients under study were on single antihypertensive drug, 39%
have two antihypertensive medications while the 9% were receiving three
antihypertensive medications.
Table (4.1.14): Shows the base line BP and the number of antihypertensive
medications used.
Number of antihypertensive medications
Base line BP single
antihypertensive two antihypertension three antihypertension
120-139\80-89 mmhg 22 (22%) 20 (20%) 6 (6%)
140-159 \ 90-99 mmhg 18 (18%) 9 (9%) 3 (3%)
160 \100 mmhg 8 (8%) 6 ( 6%) 0 (0%)
more than 160 \ 100 mmhg 4 (4%) 4 (4%) 0 (0%)

Total 52 (52%) 39 (39%) 9 (9%)

More than (52%) of patients were free from the symptoms in case and (50%) in
control, (26%) complain from headache in cases and (24%) in control group and
(12% ) complain from chest pain in control and (10%) in intervention group while
(8%) complain from dizziness in cases and burring of vision as shows in table
(4.1.15)
Table (4.1.15): Shows the symptoms related to high blood pressure
Symptoms Intervention group Control group
Blurring of vision 2 (4%) 4 (8%)
Chest pain 5 (10%) 6 (12%)
Dizziness 4 (8%) 3 (6%)
Headache 13 (26%) 12 (24%)
No symptoms 26 (52%) 25 (50%)
Total 50 (100%) 50 (100%)

46
(86%) of patients were not using special diet in control and (84%) in intervention
group while the remaining depend on low cholesterol and low protein and salt as
shows in table below.
Table (4.1.16): Shows the type of diet followed by the patients

Diet type Intervention group Control group

Low cholesterol 3 (6%) 3 (6%)
Low protein and salt 5 (10%) 4 (8%)
No special diet 42 (84%) 43 (86%)
Total 50 (100%) 50 (100%)

More than (63%) of the total patients under study were not aware about the
recommended amount of salt that can be consumed per day. (4%) of patients were
receiving salt less than 1500mg/day (1/2tea spoon) while the remaining were
receiving more than 2500mg (one tea spoonful).
Table (4.1.17) shows the amount of salt consumed by the patient’s / day
Salt amount /day Intervention group Control group
Less than 1500mg 2 (4%) 0 (0%)
2000-2500 mg 5 (10%) 5 (10%)
More than 3000mg 12 (24%) 13 (26)
I do not know 31 (62%) 32 (64%)
Total 50 (100%) 50 (100%)

(86%) of patient didn’t practice physical activity in intervention group and (88%)
in control while (26%) practice physical activity irregularly in intervention and
control group as seen in table below.

47
Table (4.1.18): Shows the practice of physical activity by the patients

Physical activity Intervention group Control group

Practice physical exercise 7 (14%) 6 (12%)
Not Practicing physical activity 43 (86%) 44 (88%)
Total 50 (100%) 50 (100%)

(18%) of them practiced walking as activity in intervention group, (16%) practiced

walking in control group and (80% ) and more without physical activity in both
group.

Table (4.1.19): Show the type of physical activity practice by patients

activities Intervention group Control group
Walking 9 (18%) 8 (16%)
Running 1 (2%) 0 (0%)
None 40 (80%) 42 (84%)
Total 100 100.0

(68%) were not following any activity in control and about (64%) not practice
physical activity in case group .
Table (4.1.20): Shows the Frequency of activities of the patient’s / week
Frequency of activity Intervention group Control group
1-3 times a week 2 (4%) 1 (2%)
Irregular 16 (32%) 15 (30%)
No activity 32 (64%) 34 (68%)
Total 50 (100%) 50 (100%)

48
(84%) were taking any food available in spite of their disease in intervention and
(86%) in control group while (2%) their intake seem suitable food for hypertensive
patients in both group.
Table (4.1.21): Shows the common daily food consumed by patients

Common food Intervention group Control group

Meats 2 (4%) 2 (4%)
Bread and kisra 5 (10%) 3 (6%)
Salad and vegetables 1(2%) 2 (4%)
Any food available 42 (84%) 43 (86%)
Total 50 (100%) 50 (100%)

(92%) of patients in intervention group were not aware about DASH diet and
(94%) in control group not aware about DASH while only 4% were aware.

Table (4.1.22): Shows the awareness of the patients about DASH

Frequency Percent
Aware about DASH 2 (4%) 2 (4%)
Not aware about DASH 46 (92%) 47 (94%)
Total 50 (100%) 50 (100%)

49
4.2. Final statistical result of both case and control groups
Table (4.2.1): The differences in systolic pressure between cases (intervention
group) and control group (n=88)

Cases Control C/I 95%

Months Mean SD Mean SD SE Lower Upper t DF P

144.1 12.9 140.3 12.1 1.4 86 0.159
Basic BP 2.7 -1.5 9.1
142.0 12.0 142.1 11.2 0.0 86 0.985
First month 2.5 -5.0 4.9
140.2 9.0 141.5 11.5 -0.6 86 0.564
Second month 2.2 -5.6 3.1
138.4 11.1 142.3 11.4 -1.6 86 0.109
Third month 2.4 -8.7 0.9
137.5 11.5 142.8 11.2 -2.2 86 0.032
Forth month 2.4 -10.1 -0.5
137.4 11.3 142.3 10.9 -2.0 86 0.045
Fifth month 2.4 -9.5 -0.1
136.8 10.7 142.4 11.1 -2.4 86 0.019
Sixth month 2.3 -10.2 -0.9
136.2 10.6 142.7 10.4 -2.9 86 0.005
Seventh month 2.2 -10.9 -2.0
136.2 10.4 143.2 10.2 -3.2 86 0.002
Eighth month 2.2 -11.4 -2.7
135.5 10.2 143.6 10.1 -3.8 86 0.000
Ninth month 2.2 -12.4 -3.8
135.0 9.6 143.3 9.2 -4.2 86 0.000
Tenth month 2.0 -12.4 -4.4

The mean value of systolic blood pressure at basic measure in cases (n=44) was
144.1±12.29 while in control group (n=44) was 140.3±12.1, which was not
significantly different (P = 0.159 > 0.05).
The mean value of systolic blood pressure at first month measure in cases (n44)
was 142.0±12.0 while in control group (n=44) was 142.1±11.2, which was not
significantly different (P = 0.985 > 0.05).
The mean value of systolic blood pressure at second month measure in cases
(n=44) was 140.2±9.0 while in control group (n=44) was 141.5±11.5, which was
not significantly different (P = 0.564> 0.05).

50
The mean value of systolic blood pressure at the third month measure in cases
(n=44) was 138.4±11.1 while in control group (n=44) was 142.3±11.4, which was
not significantly different (P = 0.109 > 0.05).
The mean value of systolic blood pressure at the fourth month measure in cases
(n=44) was 137.5±11.5 while in control group (n=44) was 142.8±11.2, which was
significantly different (lower in cases and higher in control) (P = 0.032 < 0.05).
The mean value of systolic blood pressure at the fifth month measure in cases
(n=44) was 137.4±11.3 while in control group (n=44) was 142.3±10.9, which was
significantly different (lower in cases and higher in control) (P = 0.045 < 0.05).
The mean value of systolic blood pressure at the sixth month measure in cases
(n=44) was 136.8±10.7 while in control group (n=44) was 142.4±11.1, which was
significantly different (lower in cases and higher in control) (P = 0.019 < 0.05).
The mean value of systolic blood pressure at the seventh month measure in cases
(n=44) was 136.2±10.6 while in control group (n=44) was 142.7±10.4, which was
significantly different (lower in cases and higher in control) (P = 0.005< 0.05).
The mean value of systolic blood pressure at the eighth month measure in cases
(n=44) was 136.2±10.4 while in control group (n=44) was 143.2±10.2, which was
significantly different (lower in cases and higher in control) (P = 0.032 < 0.002).
The mean value of systolic blood pressure at the ninth month measure in cases
(n=44) was 135.5±10.2 while in control group (n=44) was 143.6±10.1, which was
significantly different (lower in cases and higher in control) (P = 0.000 < 0.05).
The mean value of systolic blood pressure at the tenth month measure in cases
(n=44) was 135.0±9.6 while in control group (n=44) was 143.3±9.2, which was
significantly different (lower in cases and higher in control) (P = 0.000 < 0.05).

51
Table (4.2.2): The differences in diastolic pressure between cases (intervention
group) and control group (n=88)

Cases Control C/I 95%

Months Mean SD Mean SD SE Lower Upper t DF P

92.1 6.0 85.0 8.5 1.6 4.0 10.2 4.5 86 0.001
Basic BP
90.4 8.2 85.9 9.3 1.9 0.8 8.2 2.4 86 0.018
First month
86.6 7.0 88.8 7.1 1.5 -5.1 0.8 -1.4 86 0.152
Second month
87.9 5.6 88.2 8.0 1.5 -3.3 2.6 -0.2 86 0.817
Third month
88.1 5.7 90.2 6.8 1.3 -4.7 0.6 -1.5 86 0.134
Forth month
87.7 5.3 90.0 6.2 1.2 -4.7 0.1 -1.9 86 0.064
Fifth month
87.5 5.4 90.2 6.0 1.2 -5.1 -0.2 -2.2 86 0.032
Sixth month
86.8 5.2 90.4 6.1 1.2 -5.9 -1.1 -2.9 86 0.004
Seventh month
86.4 5.1 90.9 5.1 1.1 -6.6 -2.3 -4.1 86 0.001
Eighth month
86.5 5.2 91.2 5.7 1.2 -7.0 -2.3 -4.0 86 0.001
Ninth month
86.5 5.2 91.2 5.5 1.1 -6.9 -2.4 -4.0 86 0.001
Tenth month

The mean value of diastolic blood pressure at basic measure in cases (n44) was
92.1±6.0 while in control group (n=44) was 85±1.6, which was significantly
different (higher in cases and lower in control) (P = 0.001< 0.05).
The mean value of diastolic blood pressure at first month measure in cases (n44)
was 90.4±8.2 while in control group (n=44) was 85.9±9.3, which was significantly
different (higher in cases and lower in control)(P = 0.018< 0.05).
The mean value of diastolic blood pressure at second month measure in cases
(n=44) was 86.6±7.0 while in control group (n=44) was 88.8±7.1, which was not
significantly different (P = 0.153> 0.05).
The mean value of diastolic blood pressure at the third month measure in cases
(n=44) was 87.9±5.6 while in control group (n=44) was 88.2±8.0, which was not
significantly different (P = 0.817> 0.05).

52
The mean value of diastolic blood pressure at the fourth month measure in cases
(n=44) was 88.1±5.7 while in control group (n=44) was 90.2±6.8, which was not
significantly different (P = 0.134> 0.05).
The mean value of diastolic blood pressure at the fifth month measure in cases
(n=44) was 87.7±5.3 while in control group (n=44) was 90.0±6.2, which was not
significantly different (P = 0.064> 0.05).
The mean value of diastolic blood pressure at the sixth month measure in cases
(n=44) was 87.5±5.4 while in control group (n=44) was 90.2±6.0, which was
significantly different (lower in cases and higher in control) (P = 0.032< 0.05).
The mean value of diastolic blood pressure at the seventh month measure in cases
(n=44) was 86.8±5.2 while in control group (n=44) was 90.4±6.1, which was
significantly different (lower in cases and higher in control) (P = 0.004< 0.05).
The mean value of diastolic blood pressure at the eighth month measure in cases
(n=44) was 86.4±5.1 while in control group (n=44) was 90.9±5.1, which was
significantly different (lower in cases and higher in control) (P = 0.001< 0.005).
The mean value of diastolic blood pressure at the ninth month measure in cases
(n=44) was 86.5±5.2 while in control group (n=44) was 91.2±5.7, which was
significantly different (lower in cases and higher in control) (P = 0.001< 0.05).
The mean value of diastolic blood pressure at the tenth month measure in cases
(n=44) was 86.5±9.6 while in control group (n=44) was 91.2±5.5, which was
significantly different (lower in cases and higher in control) (P = 0.001< 0.05).

53
Discussion
 5. Discussion

This study was done on hypertensive patients to assess effectiveness of

(DASH) approach through reducing high blood pressures.

The results of this study shows that (44%) of intervention group and (46%) of
control group had pre-hypertension, (30%) of them each control and intervention
group had first stage hypertension and (10%) had blood pressure more than
160/100mmHg in intervention group; all of them were on antihypertensive drug
(52%) had single antihypertensive in intervention group,(28%) two
antihypertensive drugs in intervention group and (20%) three antihypertensive
drugs in intervention group while in control group (46%), (32%) and (22%)
respectively (table No 4.1.13 and 4.1.11).

All the study results before intervention reveal that the hypertensive patients were
aware about medication and their disease but all of them had little knowledge
about DASH for this reason their blood pressure remained uncontrolled (table No
4.1.10, 4.1.21 and 4.1.22).

In primary screen without intervention (82%) of patients who had taken

medications as prescribed by a doctor in interventional group and (80%) in control
group and in spite of that their blood pressure remained high so antihypertensive
medications alone were not sufficient to control hypertension. Additional life style
modifications like DASH plan were necessary to maintain optimal blood pressure
(table No 4.1.12).

This study shows that most of patients under study were on regular monthly follow
up, (90%) had special treating doctor in intervention group and (86%) in control
group and about 90% on regular antihypertensive drugs but still their blood

54
pressure were not controlled that may be due to lack of knowledge and awareness
about additional method and strategies like eating style, exercise and stress
reduction to control their blood pressure. While most of patients did not have
background about DASH that made it very difficult to maintain their optimal blood
pressure (table N o 4.1.9, 4.1.5 and 4.1.12).

This study shows the mean value of systolic blood pressure at basic measurement
in cases (n=44) was 144.1±12.29 while in control group (n=44) was 140.3±12.1,
which was not significantly different (P = 0.159 > 0.05) (table No 4.2.1).
The significant changes occurred in the mean value of systolic blood pressure at
the fourth month measure in cases (n=44) was 137.5±11.5 while in control group
(n=44) was 142.8±11.2, which was significantly different (lower in cases and
higher in control) (P = 0.032 < 0.05) (table No 4.2.1).
The changes became more significant in months after 4th month as the mean value
of systolic blood pressure at the 10th month measure in cases (n=44) was 135.0±9.6
while in control group (n=44) was 143.3±9.2, which was significantly different
(lower in cases and higher in control) (P = 0.000 < 0.05) (table No 4.2.1).
DASH eating plan had the greatest effect in high blood pressure and blood pressure
reduction came fast within 2 week of starting plan (55)
In 6th moth trial period blood pressure occur 12mmHg systolic in men and 11
mmHg in women while diastolic decreased by 6mmHg in men and 7 mmHg in
women (60)
More than 4th week low sodium intake is effective in reducing blood pressure (54)
Lowering sodium intake whatever eating plan can contribute in reduction of blood
pressure (55)
The results of this study are in line with that study done on United State to
compare diet containing low sodium and other with traditional eating of United

55
State of America DASH eating plan, the result of that was reducing dietary sodium
lowered blood pressure for both eating plans. The greatest blood pressure
reductions were for the DASH eating plan at the sodium intake of 1,500 milligrams
per day. Those with high blood pressure showed the greatest reductions,
importance to lowering sodium intake whatever your eating plan (55)

In the primary screening the mean value of basic diastolic blood pressure measure
in cases (n=44) was 92.1±6.0 while in control group (n=44) was 85±1.6, which
was significantly different (higher in cases and lower in control) (P = 0.001< 0.05)
(table No 4.2.2).
The changes became significant at the 6th month the mean value of diastolic blood
pressure at the sixth month measure in cases (n=44) was 87.5±5.4 while in control
group (n=44) was 90.2±6.0, which was significantly different (lower in cases and
higher in control) (P = 0.032< 0.05) (table No 4.2.2).
The changes became more significant after 6th month the mean value of diastolic
blood pressure at the 10th month measure in cases (n=44) was 86.5±9.6 while in
control group (n=44) was 91.2±5.5, which was significantly different (lower in
cases and higher in control) (P = 0.001< 0.05) (table No 4.2.2).
This result going with that done by (Whitt-Glover MC) in North Carolina which
shows no significant changes occurred in blood pressure after 12 th week of
application of the DASH approach (56)

The result of this study were in line with that study done by (Blumenthal JA,
Babyak MA) in United States of America to assess the DASH diet alone and in
combination with exercise and weight loss which shows that the blood pressure
was reduced by 16.1/9.9 mm Hg (DASH plus weight management); 11.2/7.5
mmhg (DASH alone); and 3.4/3.8 mmhg (usual diet controls) (P < .001).(57)

56
The important findings were shows significant changes (p=0.03) occurred in
systolic blood pressure after 4th month; while in diastolic blood pressure significant
changes (p= 0.032) occurred after 6th month and became more significant in next
months.

Some of studies done were different with this results in the time of blood pressure
starting to decline, like study done by national institutes of health and national
heart, lung and blood institute department of health and human services in U.S
(united state) participants who followed both the plan that included more fruits and
vegetables and the DASH eating plan had reduced blood pressure. But the DASH
eating plan had the greatest effect, especially for those with high blood pressure.
Furthermore, the blood pressure reductions came fast within 2 weeks of starting the
plan.(55).

Based on the research findings, the DASH diet could be adopted as part of current
national recommendations for the prevention and treatment of high BP.

First line of prevention and management of hypertension is life style change

include dietary changes, physical exercise and weight reduction; potential affect is
similar to single antihypertensive medication (54).

57
Conclusion and recommendations
 6. Conclusion and recommendation

6.1. Conclusion

DASH eating plan is a diet rich in fruits, vegetables, and low-fat dairy foods,
reduced saturated and total fat; application of this program lead to significant
substantially changes, it is clear that both systolic and diastolic blood pressure of
the cases (intervention group) decreased compared with control group, with no
significant differences at basic measure, then significantly different by 4th month
in systolic BP and by 6th month in diastolic BP (lower in cases and higher in
control).

58
6.2. Recommendation

According to the results of case control study the researcher recommends the
following:-

6.2.1. Education for health care workers, social workers and nutritionist about
dietary approach to stop hypertension (DASH) should be rendered.

6.2.2. DASH is recommended to be introduced in curriculum of health, nursing

and nutritional sciences

6.2.3. Extensive education should be extended to the community on DASH

especially to hypertensive patients.

6.2.4. It is necessary to apply a nutritional approach to all hypertensive patients

because it could minimize both the healthcare workload and the high cost for
therapy in clinical area.

6.2.5. Further studies should be conducted in large group of patients to evaluate the
possibility of clinical application to other chronic diseases like heart disease is
recommended.

6.2.6. Government should support poor hypertensive patients to follow DASH and
to have antihypertensive drugs in their hands.

59
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68
 ANNE (I)

In The Name of God, More Gracious Most Merciful

National Ribat University

Faculty of graduate and scientific research

This research is for scientific reasons only. All data and informations will be kept
in a confidential manner. This data will be collected to assess basic knowledge
about hypertension and eating style.

A.GENERAL INFORMATION
1. Name ___________________________________________________________
2. Gender____ Male________________ ( ) _______________Female ( ).
3. Age
a. up 30 years_______________ ( )
b. 31-60 year________________ ( )
c. More than 60 year___________( )
4. Occupation
a. Employee____________________________________( )
b. Labor________________________________________( )
c. House wife___________________________________( )
d. Farmer______________________________________( )
e. Other_______________________________________( )
5. Income\month
a. Less than 1000 Sudanese pounds_____________________( )
b. 1000-2000 Sudanese pounds________________________( )
c. More than 2000 Sudanese pounds____________________( )
6. Address _________________________________________________________
7.Telephone number ________________________________________________
8. Do you have special treating doctor?
69
Yes __________________ ( ) No___________________ ( )n
9. Are there any other medical problems you are being treated for?
Yes _________________ ( ) No____________________ ( )
If yes, please tick
a. Diabetes ____________________( )
b. Heart disease________________ ( )
c. Asthma_____________________( )
d. Renal disease_________________( )
e. Others _____________________ ( )
10. What are your strategies to control your blood pressure in addition to
medication?
a) Eating style____________________________________( )
b) Exercising_____________________________________( )
c) Reducing stress_________________________________( )
d) reducing weight_________________________________( )
B. about high blood pressure and diet
1. How often do you meet your doctor for blood pressure checkups?
a) Monthly__________________________________( )
b) 4 times\year ______________________________ ( )
c) 2 times\year_______________________________ ( )
d) once a year________________________________ ( )
2. Are you on antihypertensive medication?
Yes_________________________ ( ) No.__________ ( )
If yes please list:
a.______________________b__________________________________________
c._____________________d___________________________________________
e._____________________f___________________________________________
70
3. Have you been regularly taking your medications as prescribed by your doctor?
Yes______________________ ( ) No_______________________ ( )
4. Your last blood pressure:
a. 120-139\80-89 mmhg______________________ ( )
b. 140-159\90-99 mmhg______________________ ( )
c. 160\100 mmhg____________________________( )
d. More than 160\100 mmhg___________________( )
5. Do you measure your blood pressure at home?
Yes______________________ ( ) No ________________________( )
6. Have you suffered from the following symptoms?
a) Blurring of vision_______________________________________ ( )
b) Chest Pain_____________________________________________ ( )
c) Dizziness______________________________________________ ( )
d) Headache_____________________________________________ ( )
e) None__________________________________________________( )
7. Does high blood pressure affect the ability to perform your usual daily
activities?
Yes______________________ ( ) No ________________________ ( )
8. Select the type of diet you are following.
1. Low Carbohydrate ( Sugar)__________________________( )
2. Low Cholesterol___________________________________( )
3. Low Protein and low Salt ___________________________( )
4. Vegetarian________________________________________( )
5. No Special Diet____________________________________( )
9. Amount of salt (sodium) per day:
1. less than 1500mg per day(1/2 small spoon) ________ ( )
2. 2000 -2500 mg per day (3/4 spoon) _______________ ( )

71
 3. More than 3000mg per day (1 tea spoon)______________ ( )
4. I do not know _______________________________ ( )
10. Do you practice any physical activity?
Yes____________________ ( ) No_____________________________ ( )
If yes tick it please:
a. walking_____________________( ) b. Running_____________ ( )
c. Swimming _________________ ( ) d. None_______________ ( )
11. How often do you practice physical activity?
a. 1-3 times a week __________________________________( )
b. 4-5 times a week__________________________________ ( )
c. 6-7 times a week__________________________________ ( )
d. Irregularly ______________________________________ ( )
e. none___________________________________________ ( )
12. Your common daily food includes:
1. meats(fish, chicken, red meat)__________________( )
2. Bread and Kisra______________________________( )
3. Salad and vegetables __________________________( )
4. Any food available ____________________________( )
* CONTACT INFORMATION
1. Would you like to participate in DASH and high blood pressure educational
program?
Yes______________________( ) No ________________________( )

2. What days are best to call you?

Sat _______ Sun _________ Mon________ Tue________ Wed_________ Thu
_________Fri _________Any Day__________________________________

72
3. What are the best times to call you?
7-9 am______________ ( ) 9-11 am________________________ ( )
11 am-1 pm__________ ( ) 1-3pm_________________________ ( )
3-5 pm______________ ( ) Anytime_______________________ ( )

Do you know what dietary approach to stop hypertension?

Yes ______________________ ( ) No________________________( )

Thank a lot for your co-operation and participation

73
 ‫بسم هللا الرحمن الرحيم‬
‫)‪ANNEX (II‬‬

‫حمية داش الغذائية لتقليل‬

‫إرتفاع ضغط الدم‬
‫)‪(DASH‬‬

‫اعداد الباحث‬
‫ابراهيم ابكر ابراهيم‬

‫‪0914460169‬‬

‫‪74‬‬
 0122137836

DASH EATING PLAN

75
 ‫بسم هللا الرحمن الرحيم‬
‫)‪ (DASH‬حمية داش الغذائية‬
‫ماهي حمية داش‪:‬‬
‫داش هي أحد أنواع الحمية الحديثة التي صممت أصال للتحكم في ضغط الدم املرتفع‪ ،‬وتقوم حمية داش‬
‫على تناول املزيد من الفواكه والخغروات ومنتجات األلبان القليلة الدسم أو منزوعة الدسم ُّ‬

‫ملاذا حمية داش الغذائية‪:‬‬

‫حمية داش تساعد على تحسن االستجابة للعالج وتساعد على تخفيض الكوليسترول‪ ،‬كما‬
‫تساعد على االستجابة للعالج باألنسولين عند انخفاض الوزن وممارسة الرياضة يعمل علي تقليل ضغط‬
‫الدم‪ .‬واجمل مافي في حمية داش هو بساطة تطبيقها فهي ال تطلب مكونات غريبة او صعبة االيجاد حيث‬
‫يتوفر كل مايحتاجة االنسان لتطبيقها في اقرب سوق مركزي او سوق خغار ‪ .‬ان كل ما علي الفرد القيام‬
‫به هو ان يقلل من الدهون ويغاعف مقدار الفواكه والخغروات ويتناول منتجات البان قليلة الدسم او‬
‫منزوعة الدسم‪ .‬فحمية داش كما يصفها احد الخبراء حمية لجميع االمراض حيث تحتوي علي الفواكه‬
‫والخغروات للحد من زيادة ضغط الدم ‪ ،‬والكالسيوم ملحاربة هشاشة العظام‪ ،‬وتبتعد من الدهون‬
‫املشبعة لغمان صحة القلب‪.‬‬

‫كمية امللح (الصوديوم) املسموح بة خالل اليوم‪ُّ :‬‬

‫يمكنك ان تستهلك ما يصل إلى ‪ 2400 - 1،500‬ملغ من الصوديوم يوميا (مايعادل نصف ملعقة‬
‫صغيرة)‪ .‬الهدف من حمية داش الغذائية هو تقليل كمية الصوديوم في النظام الغذائي الخاص بك‬
‫مقارنة مع ما قد تحصل علية في اتباع نظام غذائي أكثر تقليدية‪ ،‬والتي يمكن أن تصل إلى ‪ 3،500‬ملغ من‬
‫الصوديوم يوميا أو أكثر‪.‬‬
‫هذا النظام الغذائي توص ي للحد من الصوديوم إلى ‪ 1،500‬ملليغرام في اليوم إذا كنت من كبار‬
‫السن‪ ،‬أو لديك ارتفاع ضغط الدم‪ ،‬ومرض السكري أو أمراض الكلى املزمنة ‪ .‬يوجد امللح بكميات‬
‫كبيرة في االغذية والخضروات املعلبة لذلك يجب التقليل من هذا النوع من الغذاء‪.‬‬

‫‪76‬‬
 ‫البوتاسيوم ومصادرة الغذائية ‪:‬‬

‫نقصان كمية البوتاسيوم في الجسم يودي الي زيادة ضغط الدم حسب العديد من الدراسات‬
‫اما املصادر الغذائية للبوتاسيوم تشمل السمك والفواكه والبقول واللحوم والدواجن والحبوب‬
‫الكاملة والخضروات ويوجد بتركيزات أعلى في األفوكادو واملوز والكمثرى والبلح والعسل األسود واألرز‬
‫البني والتين والفاكهة املجففة والزبيب والبطاطس والثوم والبصل والقرع العسلي ومنتجات األلبان‬
‫وينصح األشخاص الذين يتناولون مدرات البول كعالج لغضط الدم املرتقع بتناول فاكهة مثل املوز‬
‫والبرتقال والطماطم وذلك ملحتواها العالي من البوتاسيوم‪.‬‬

‫للحصول علي فعالية برنامج داش الغذائي اتبع الوجبات الغذائية االتية‪:‬‬
‫‪ 8-7‬حصص (وجبات) من الحبوب الكاملة‬
‫‪.‬الحصة(الوجبة) هي =‪ 1‬شريحة الخبز ‪ 1 ،‬كوب من الحبوب ‪ /‬الحبوب ‪/‬املشكلةمجموعة انواع من‬
‫الحبوب ‪ ،‬أو ‪ 1.2‬كوب معكرونة مطبوخة ‪ /‬األرز‪.‬‬
‫‪ 5-4‬حصص من الخضار ‪ /‬الخضروات الجذرية‬
‫على سبيل املثال‪ ،‬القرنبيط والجزر والجزر األبيض والذرة والكرنب والبصل والبطاطا ‪ ،‬والسبانخ ‪،‬‬
‫والطماطم أو كوسة‪.‬‬
‫الحصة = ‪ 2.5‬كوب الخضار الورقية‪ 1.2 ،‬كوب من الخضار النيئة أو املطبوخة‪ 1.2 ،‬كوب من عصير‬
‫الخضار‬
‫‪ 5-4‬حصص من الفاكهة‬
‫على سبيل املثال ‪ :‬التفاح والبرتقال والكمثرى واملوز والخوخ واألناناس والفراولة والعنب والزبيب‬
‫والعصير ‪ ،‬والتوت ‪ ،‬الكشمش‪ ،‬والعنب والكيوي‪(.‬حسب النوع املتوفر) الحصة = ‪ 1‬فاكهة متوسطة‪،‬‬
‫ونصف الفاكهة املجففة كوب‪ 1.2 ،‬كوب فاكهة ‪ /‬عصير التوت او أي من الفواكة املذكورةعالية‪.‬‬
‫‪ 3-2‬حصص من منتجات األلبان منخفضة الدهون او خال من الدهون‬
‫على سبيل املثال ‪ :‬الحليب القليل الدسم او الحليب الخالي من الدسم‪ ،‬والجبن قليل الدسم والزبادي‬
‫قليل الدسم‪.‬‬
‫‪ 2-0‬حصص من اللحوم واألسماك والدواجن والبيض‬
‫على سبيل املثال ‪ :‬اللحوم الخالية من الدهون والدواجن ‪ ،‬األسماك‪.‬‬
‫‪77‬‬
 ‫الحصة = ‪ 85‬غراما من اللحم ‪ /‬الدجاج منزوعة الجلد‪ ،‬و ‪ 100‬غراما من السمك والبيض‪.‬‬
‫• املكسرات‪ ،1-0‬والبذور والفاصوليا والبقول ‪ 5-4‬مرات ‪ /‬األسبوع‬
‫على سبيل املثال ‪ :‬اللوز والبندق واملكسرات والفول السوداني والجوز‪ ،‬وبذور عباد الشمس ‪ ،‬وزبدة‬
‫الفول السوداني والفاصوليا والعدس ‪ ،‬أو البازالء‪.‬‬
‫الحصة=‪ 2‬معلقة كبيرة من زبدة الفول السوداني‪ 2‬مالعق كبيرة من البذور ‪ 1.5‬كوب ‪ /‬العدس او‬
‫فاصولياء ‪ 2 ،‬مالعق طعام من املكسرات‪.‬‬
‫• ‪ 3-2‬حصص من الدهون (الوجبات التي تحتوي علي الدهون)‬
‫على سبيل املثال‪ ،‬زيت الزيتون ‪ ،‬زيت وقليل الدسم من املايونيز الخفيف ‪. ،‬‬
‫‪ 1‬ملعقة صغيرة من السمن تخدم = ‪ 1 ، 1‬ملعقة صغيرة زيت‪ 1 ،‬ملعقة مايونيز خفيف‪ 2 ،‬مالعق من‬
‫صلصة قليلة الدسم‬
‫• ‪ 1-0‬من السكر‬
‫على سبيل املثال ‪ ،‬السكر واملربى واملربى والحلوى ‪ ،‬اآليس كريم شربات‪،‬‬

‫الحصة = ‪ 1‬ملعقة طعام من السكر ‪ 1 ،‬ملعقة كبيرة من املربى ‪ /‬مربى البرتقال‪ ،‬كوب شربات ‪، 1.2‬‬
‫‪ 2.4‬ديسيلتر من العصير الشراب أو ‪ 5‬حلوى حسب املتاح‪.‬‬

‫‪78‬‬
 ‫مستشفيات منطقة الخرطوم ‪ANNEX III‬‬

‫االسـره‬ ‫الـمـوقـع‬ ‫الوحدة بالمحلية‬ ‫المستشفى‬ ‫الرقم‬

‫‪751‬‬ ‫شارع الطابية‬ ‫بلدية الخرطوم‬ ‫الخرطوم التعليمي‬ ‫‪1‬‬

‫‪147‬‬ ‫شارع اللواء محمد نجيب‬ ‫بلدية الخرطوم‬ ‫ابن سينا‬ ‫‪2‬‬

‫‪141‬‬ ‫شارع القصر‬ ‫بلدية الخرطوم‬ ‫الـذره‬ ‫‪3‬‬

‫‪274‬‬ ‫شارع الطابية‬ ‫بلدية الخرطوم‬ ‫الشـعب‬ ‫‪4‬‬

‫‪270‬‬ ‫الصحافه شرق‬ ‫بلدية الشهداء وسوبا‬ ‫ابراهيم مالك‬ ‫‪5‬‬

‫‪209‬‬ ‫الصحافه االمتداد‬ ‫بلدية الشهداء وسوبا‬ ‫االكاديميه‬ ‫‪6‬‬

‫‪82‬‬ ‫شارع القصر‬ ‫بلدية الخرطوم‬ ‫االنف واالذن والحنجره‬ ‫‪7‬‬

‫‪42‬‬ ‫شارع مستشفى الخرطوم‬ ‫بلدية الخرطوم‬ ‫الجلديه‬ ‫‪8‬‬

‫‪35‬‬ ‫شارع المك نمر‬ ‫بلدية الخرطوم‬ ‫االسـنان‬ ‫‪9‬‬

‫‪280‬‬ ‫شارع مستشفى الخرطوم‬ ‫بلدية الخرطوم‬ ‫جعفر ابنعوف‬ ‫‪10‬‬

‫‪67‬‬ ‫شارع النيل‬ ‫بلدية الخرطوم‬ ‫عبدالفضيل‬ ‫‪11‬‬

‫‪0‬‬ ‫الخرطوم‬ ‫الخرطوم(أ‪+‬ب)‬ ‫جابر ابوالعز‬ ‫‪12‬‬

‫‪144‬‬ ‫الكالكله‬ ‫الكالكالت‬ ‫التركي‬ ‫‪13‬‬

‫‪81‬‬ ‫جبل اولياء‬ ‫الكالكالت‬ ‫جبل اولياء‬ ‫‪14‬‬

‫‪171‬‬ ‫مايو‬ ‫النصر واالزهري‬ ‫بشائر‬ ‫‪15‬‬

‫‪30‬‬ ‫الجريف غرب‬ ‫الخرطوم شرق‬ ‫السـويدي‬ ‫‪16‬‬

‫‪79‬‬
 ‫مستشفيات منطقة ام درمان‬

‫االسـره‬ ‫الـمـوقـع‬ ‫الوحدة بالمحلية‬ ‫المستشفى‬ ‫الرقم‬

‫‪498‬‬ ‫بلدية ام درمان‬ ‫بلدية ام درمان‬ ‫ام درمان التعليمي‬ ‫‪1‬‬
‫‪290‬‬ ‫بلدية ام درمان‬ ‫بلدية ام درمان‬ ‫حوادث االطفال امدرمان‬ ‫‪2‬‬
‫‪32‬‬ ‫شارع العرضه‬ ‫بلدية ام درمان‬ ‫الوالدين‬ ‫‪3‬‬
‫‪33‬‬ ‫شارع العرضه‬ ‫بلدية ام درمان‬ ‫عوض حسين‬ ‫‪4‬‬
‫‪118‬‬ ‫شارع العرضه‬ ‫بلدية ام درمان‬ ‫التجاني الماحي‬ ‫‪5‬‬

‫‪100‬‬ ‫المالزمين‬ ‫بلدية ام درمان‬ ‫المناطق الحاره‬ ‫‪6‬‬

‫‪181‬‬ ‫السوق الشعبي‬ ‫بلدية ام درمان‬ ‫الصـداقه الصيني‬ ‫‪7‬‬

‫‪286‬‬ ‫شارع الموردة‬ ‫بلدية ام درمان‬ ‫الـوالده‬ ‫‪8‬‬
‫‪135‬‬ ‫ابوعنجة‬ ‫بلدية ام درمان‬ ‫ابوعنجه‬ ‫‪9‬‬
‫‪129‬‬ ‫الثوره االولى‬ ‫بلدية ام درمان‬ ‫السـعودي‬ ‫‪10‬‬
‫‪70‬‬ ‫الثوره الثامنه بالنص‬ ‫الثورات كرري‬ ‫النو‬ ‫‪11‬‬
‫‪165‬‬ ‫الثوره الرابعه بالنص‬ ‫الثورات كرري‬ ‫البلك‬ ‫‪12‬‬
‫‪25‬‬ ‫الريف الشمالي ام درمان‬ ‫كرري‬ ‫السروراب‬ ‫‪13‬‬
‫‪50‬‬ ‫الريف الشمالي ام درمان‬ ‫كرري‬ ‫الجزيره اسالنج‬ ‫‪14‬‬
‫‪13‬‬ ‫الريف الشمالي ام درمان‬ ‫كرري‬ ‫ام كتي‬ ‫‪15‬‬
‫‪58‬‬ ‫الفتح ‪2‬‬ ‫كرري‬ ‫الفتح‬ ‫‪16‬‬
‫‪45‬‬ ‫ابوسعد والريف الجنوبي الريف الجنوبي ام درمان‬ ‫جبيل الطينه‬ ‫‪17‬‬
‫‪50‬‬ ‫الفتيحاب ابوسعد‬ ‫ابوسعد والريف الجنوبي‬ ‫ابوسعد‬ ‫‪18‬‬
‫‪65‬‬ ‫الحارة ‪18‬‬ ‫االمير‬ ‫امبده الحارة ‪18‬‬ ‫‪19‬‬

‫‪80‬‬
 ‫مستشفيات منطقة بحري‬

‫االسـره‬ ‫الـمـوقـع‬ ‫الوحدة بالمحلية‬ ‫المستشفى‬ ‫الرقم‬

‫‪456‬‬ ‫شارع السيد علي‬ ‫بلدية بحري‬ ‫بحري التعليمي‬ ‫‪1‬‬
‫‪154‬‬ ‫بحري المزاد‬ ‫بلدية بحري‬ ‫احمد قاسم لالطفال‬ ‫‪2‬‬
‫‪88‬‬ ‫بحري المزاد‬ ‫بلدية بحري‬ ‫احمد قاسم لجراحة القلب‬ ‫‪3‬‬

‫‪81‬‬
 ‫والكلى‬
‫‪9‬‬ ‫الصافيه‬ ‫بلدية بحري‬ ‫حاج الصافي‬ ‫‪4‬‬
‫‪54‬‬ ‫مستشفى بحري‬ ‫بلدية بحري‬ ‫طـه بعشر‬ ‫‪5‬‬

‫‪202‬‬ ‫الحاج يوسف الردميه‬ ‫شرق النيل‬ ‫البان جديد‬ ‫‪6‬‬

‫‪134‬‬ ‫بعد كبري شرق النيل‬ ‫شرق النيل‬ ‫شـرق النيل‬ ‫‪7‬‬
‫‪72‬‬ ‫ام ضوابان‬ ‫وادي سوبا‬ ‫ام ضوابان‬ ‫‪8‬‬
‫‪44‬‬ ‫ابودليق‬ ‫العيلفون‬ ‫ابودليق‬ ‫‪9‬‬
‫‪26‬‬ ‫ودابوصالح‬ ‫ودابوصالح‬ ‫ودابوصالح‬ ‫‪10‬‬
‫‪48‬‬ ‫قـري‬ ‫ريفي بحري‬ ‫الصداقه قـري‬ ‫‪11‬‬
‫‪31‬‬ ‫الكباشي‬ ‫ريفي بحري‬ ‫الكباشي‬ ‫‪12‬‬
‫‪35‬‬ ‫الدروشاب شمال‬ ‫بحري شمال‬ ‫علي عبدالفتاح‬ ‫‪13‬‬

‫موقع وزارة الصحة االتحادية‬

‫‪82‬‬
 ANNEX (IV)

Cases (intervention group) follow up sheet

Ca Basi First Seco Thir Four Five Six Seve Eigh Nine Ten note
se c BP mon nd d mon mon mon n t mon mon s
na th mon mon th th th mon mon th th
me th th th th
1 129/ 126/ 126/ 114/ 120/ 126/ 128/ 129/ 126/ 120/ 126/
92 84 87 82 86 85 88 86 85 87 87
2 130/ 129/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
100 97 87 92 97 97 97 87 87 92 92
3 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
88 88 82 88 88 88 82 82 82 82 82
4 160/ 156/ 150/ 160/ 160/ 160/ 160/ 156/ 150/ 156/ 126/
100 125 95 100 100 100 100 95 95 95 95
5 130/ 130/ 136/ 130/ 130/ 130/ 128/ 128/ 128/ 130/ 130/
95 95 76 90 90 90 88 88 88 88 87
6 110/ 111/ 137/ 136/ 116/ 137/ 136/ 137/ 137/ 130/ 130/
90 80 82 84 82 82 84 82 82 82 82
7 130/ 130/ 130/ 130/ 130/ 126/ 120/ 126/ 126/ 125/ 125/
90 87 87 87 86 86 86 86 86 85 85
8 136/ 136/ 157/ 129/ 130/ 130/ 130/ 127/ 130/ 130/ 130/
97 95 90 89 90 90 90 89 89 89 89
9 135/ 135/ 130/ 135/ 135/ 135/ 135/ 130/ 130/ 130/ 130/
87 85 80 87 85 85 85 80 80 80 80
10 139/ 139/ 135/ drop
90 87 87 ped
11 160/ 160/ 160/ 155/ 155/ 150/ drop
100 95 95 95 95 95 ped
12 180/ 180/ 140/ 170/ 170/ 170/ 170/ 175/ 175/ 165/ 165/
110 110 80 105 105 100 100 100 100 100 100

83
13 153/ 150/ 150/ 150/ 150/ 150/ 150/ 145/ 145/ 145/ 145/
81 80 80 80 80 80 80 80 80 80 80
14 160/ 140/ 140/ 135/ 130/ 130/ 130/ 128/ 130/ 130/ 130/
85 80 80 80 80 80 80 79 80 80 80
15 160/ 150/ 150/ 150/ 145/ 150/ 150/ 155/ 155/ 155/ 155/
100 100 95 95 95 95 95 95 95 95 95
16 140/ 140/ 140/ 135/ 135/ 135/ 135/ 135/ 135/ 130/ 136/
90 90 88 87 87 88 88 88 88 86 86
17 160/ 165/ 160/ 160/ 165/ 165/ 160/ 155/ 155/ 155/ 155/
90 87 87 87 87 87 86 86 86 86 86
18 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 125/ 125/ 125/
87 86 87 87 87 85 85 85 80 80 80
19 154/ 154/ 154/ 154/ 150/ 150/ 145/ 145/ 145/ 145/ 145/
90 83 83 83 82 82 82 82 82 82 82
20 140/ 140/ 140/ 135/ 130/ 130/ 130/ 130/ 130/ 125/ 125/
95 90 90 90 90 90 90 90 90 90 90
21 170/ 170/ 160/ 160/ 160/ 155/ 155/ 155/ 150/ 150/ 150/
100 90 90 95 95 90 90 90 90 90 90
22 140/ 140/ 130/ 130/ 130/ 130/ 135/ 130/ 130/ 130/ 130/
90 90 90 80 85 85 85 80 80 80 80
23 160/ 160/ 155/ 155/ 155/ 155/ 150/ 150/ 150/ 150/ 150/
90 90 85 85 85 85 80 80 80 80 80
24 140/ 140/ 135/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
80 80 80 80 80 80 80 80 80 80 80
25 131/ 131/ 130/ 130/ 120/ 120/ 120/ 120/ 120/ 125/ 120/
84 84 85 80 80 80 80 80 80 80 80
26 150/ 150/ 145/ 145/ 145/ 145/ 140/ 140/ 140/ 140/ 140/
95 95 95 90 90 90 90 90 90 90 90
27 163/ 160/ 155/ 155/ 155/ 155/ 150/ 150/ 150/ 150/ 150/
96 95 90 90 90 90 88 88 88 88 88

84
28 150/ 145/ 145/ 145/ 140/ 140/ 135/ 135/ 135/ 130/ 130/
100 95 95 95 95 95 95 95 95 90 90
29 140/ 140/ 135/ 135/ 138/ 130/ 130/ 130/ 130/ 130/ 130/
90 90 88 88 88 87 88 88 88 85 85
30 130/ 136/ 130/ 125/ 125/ 125/ 125/ 125/ 125/ 125/ 125/
86 86 85 85 85 85 85 85 85 85 85
31 140/ 140/ 140/ 135/ 135/ 130/ 130/ 130/ 130/ 130/ 130/
90 90 88 88 88 85 85 85 85 85 85
32 130/ 130/ 125/ 125/ 130/ 125/ 125/ 125/ 125/ 125/ 125/
85 80 80 80 80 80 80 80 80 80 80
33 150/ 150/ 140/ 140/ 140/ 140/ 140/ 140/ 135/ 135/ 135/
95 90 90 90 90 90 90 90 88 88 88
34 140/ 135/ 135/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
90 88 88 85 85 85 85 85 85 85 85
35 140/ 135/ 135/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
88 87 87 85 85 85 85 85 85 85 85
36 150/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/
90 85 85 85 85 85 85 85 84 84 84
37 150/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/
90 85 85 85 85 85 85 85 84 84 84
38 150/ 145/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/
100 95 95 95 95 95 95 95 95 95 95
39 150/ 145/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/
100 95 95 95 95 95 95 95 85 95 95
40 160/ 150/ 150 100 drop
110 110 ped
41 160/ 155/ 150/ drop
100 100 97 ped
42 150/ 145/ 145/ 140/ 140/ 140/ 140/ 140/ 140/ 140/ 140/
90 88 88 88 88 88 88 88 88 88 88

85
43 130/ 130/ 130/ 130/ 128/ 128/ 128/ 130/ 130/ 130/ 130/
88 85 85 85 85 85 85 85 85 85 85
44 140/ 140/ 140/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
90 90 85 85 85 85 85 85 85 85 85
45 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/ 130/
88 88 85 85 85 85 85 85 85 85 85
46 150/ 150/ 140/ 140/ 140/ drop
88 88 85 85 85 ped
47 160/ 155/ 155/ 150/ 150/ 150/ 150/ 140/ 140/ 145/ 145/
100 98 98 95 95 95 95 95 95 95 95
48 150/ 150/ 145/ 140/ 140/ 135/ 135/ 135/ 135/ 130/ 130/
96 95 90 90 90 88 88 88 88 88 88
49 150/ 150/ 145/ 140/ 140/ 135/ 135/ 135/ 140/ 140/ 140/
96 95 90 90 90 88 88 88 88 88 88
50 150/ 150/ 145/ 145/ 140/ 145/ 145/ 145/ 145/ 140/ 140/
98 97 97 97 95 95 95 95 95 95 95

Researcher

IBRAHIM ABBAKR IBRAHIM

Mobile 0914460169 ________ 0122137836

86
 ANNEX (V)

Control follow up sheet

Case Basic First Second Third Four Five Six Seven Eight Nine Ten notes
name BP month month month month month month month month month month
1 128/73 130/80 111/71 110/80 111/80 110/80 110/82 120/82 120/82 120/82 120/82
2 140/88 136/90 dropped
3 150/100 150/100 149/100 148/100 140/100 150/100 146/100 140/100 148/100 155/100 149/100
4 136/72 138/80 130/80 130/80 130/80 130/80 130/80 130/80 130/80 130/80 130/80
5 110/70 130/92 130/92 130/92 130/95 130/95 130/95 130/95 130/95 130/95 130/95
6 128/88 128/88 130/88 130/88 130/90 130/90 130/90 130/88 130/88 130/88 130/88
7 160/90 160/90 150/95 150/90 150/95 150/90 150/90 150/90 150/90 150/90 150/90
8 129/87 129/88 130/85 130/85 130/87 130/87 130/87 130/87 130/87 130/87 130/87
9 160/80 160/79 140/80 140/60 140/80 140/80 140/80 150/80 150/80 150/80 150/80
10 134/86 134/86 140/90 dropped
11 128/77 130/80 120/80 120/80 125/80 125/80 120/80 120/77 120/88 133/85 140/90
12 120/80 120/70 130/80 130/80 135/85 135/80 135/80 135/80 130/80 130/80 130/80
13 140/90 140/90 140/90 140/90 140/90 140/92 140/92 140/92 140/92 140/92 140/92
14 130/80 130/80 140/90 140/90 140/92 140/92 140/92 140/92 140/92 140/92 140/92
15 133/66 133/66 140/80 140/80 140/80 140/80 140/80 140/80 140/85 140/85 140/85
16 120/70 160/50 150/90 150/90 150/90 150/90 150/90 150/90 150/90 150/90 150/90
17 138/79 138/79 140/92 140/90 140/90 140/90 140/92 140/92 140/92 140/92 140/90

87
18 130/90 130/90 130/90 140/90 140/92 140/90 140/90 140/92 135/90 140/92 140/90
19 140/80 140/80 140/92 140/92 140/95 140/95 140/95 140/95 140/95 140/95 140/95
20 140/85 140/87 140/90 140/80 140/85 140/85 140/85 140/90 140/90 140/90 140/90
21 139/78 140/80 139/78 139/75 140/80 139/80 139/80 130/80 140/88 140/88 140/87
22 157/100 155/100 157/100 157/105 156/100 140/105 150/100 150/100 150/100 150/100 150/100
23 160/100 160/100 160/105 160/110 160/100 150/100 150/100 150/100 150/100 150/105 150/105
24 140/80 140/80 140/80 140/85 140/85 140/85 140/90 140/88 140/90 140/90 140/90
25 160/99 160/100 169/99 160/98 160/105 160/100 160/98 160/100 160/98 150/100 150/100
26 130/80 130/82 130/80 130/80 130/85 130/86 130/86 130/88 136/90 130/88 133/90
27 140/90 140/90 140/95 140/95 140/95 140/95 145/95 150/95 150/90 150/95 150/95
28 160/100 160/100 160/105 160/100 dropped
29 130/80 130/80 130/80 135/80 140/80 140/85 140/85 140/85 140/85 140/85 140/85
30 150/96 150/96 155/100 155/100 155/100 155/100 155/100 155/100 155/100 155/100 155/100
31 150/96 150/96 155/100 155/100 155/100 155/100 155/100 150/98 150/98 155/100 155/100
32 130/80 130/82 130/82 130/82 130/82 130/85 130/85 140/90 140/90 140/90 140/90
33 138/80 130/82 130/82 130/82 130/82 130/85 130/85 140/90 140/90 140/90 140/90
34 150/90 dropped
35 140/88 140/88 140/88 140/90 140/90 140/90 140/90 140/90 140/90 140/90 140/90
36 140/80 140/88 140/88 140/90 140/90 140/90 140/90 140/90 140/90 140/90 140/90
37 160/90 157/93 dropped
38 140/88 140/88 145/90 145/90 145/90 145/90 145/90 140/90 140/90 140/95 145/90
39 140/88 140/88 145/90 145/90 145/90 145/90 145/90 140/90 140/90 140/95 140/95

88
40 150/90 150/90 150/90 155/90 155/92 155/92 155/92 155/92 155/92 155/90 155/92
41 150/90 150/90 150/90 155/90 155/92 155/92 155/92 155/92 155/92 140/90 155/92
42 140/88 145/90 145/90 145/90 145/95 145/95 145/90 140/90 140/90 140/90 140/90
43 140/88 145/90 145/90 145/90 145/95 145/95 145/90 140/90 140/90 140/90 140/90
44 140/88 150/88 150/85 150//85 150/88 150/88 150/88 155/88 155/88 155/88 155/88
45 145/98 140/100 dropped
46 160/90 160/92 160/99 160/94 160/90 160/92 160/92 160/90 150/93 163/93 156/98
47 150/90 150/90 155/92 155/92 160/95 160/95 160/95 160/95 163/96 160/95 160/95
48 160/90 160/92 160/90 160/90 160/90 160/92 160/92 160/90 160/92 160/92 160/92
49 150/98 160/100 160/105 dropped
50 150/96 150/90 155/92 155/92 160/95 160/94 159/93 157/98 160/92 163/98 154/100

Researcher

IBRAHIM ABBAKR IBRAHIM

Mobile 0914460169 ________ 012213783

89
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