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Archived Comments for: Hypertension management algorithm for type 2 diabetic patients applied in primary care

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  1. remarks on Hypertension management algorithm for type 2 diabetic patients applied in primary care

    Paul Smits, de HOEDT

    22 June 2015

    Letter to the editor

    Hypertension management algorithm for type 2 diabetic patients applied in primary care
    Luciana V Viana, Cristiane B Leitão, Maria F Grillo, Ennio P C C Rocha, Juliana K Brenner, Rogerio Friedman and Jorge L Gross : Diabetology and Metabolic Syndrome 2013, 5:52

    Paul Smits, general practitioner with special interest in cardiovascular disease, Netherlands

    This interesting primary care based study studied the results of the use of an algorithm in obtaining blood pressure under the threshold of the American Diabetes Association and the Joint National Committee on Prevention. Almost half of the studied population did not reach blood pressure below the threshold, even when the new recommendations of the ADA 2013 were considered as target levels.

    I would like to present a few remarks. Firstly, the authors mention that the study population was recruited from a primary care unit responsible for the health of approximately 40.000 people. From that population only 117 patients with diabetes type 2 where included. 90% of them were diagnosed with hypertension. Regarding a prevalence of about 5,8% in Brazil (1), more than 2000 diabetics must be present in this population. This makes me wonder how representative the studied cohort is compared to the whole population.

    The result of the run-in period is remarkable. The decline in blood pressure is as steep as in the intervention period. The decline in diastolic tension is even steeper, suggesting that medication does not add to the effect of lifestyle intervention. Of course a two-arm study comparing the both interventions would have made this point more clear. As mentioned there is evidence that dietary changes can improve hypertension in type 2 diabetics (2). The decline of blood pressure after applying the DASH diet was the same as in the studied algorithm.

    Older people tend to benefit from a higher blood pressure (3). It would therefore be interesting to investigate the age of the individuals not reaching the threshold blood pressure. Maybe older people should have higher threshold values. Unfortunately these data where not provided.

    The authors conclude that new strategies are needed to improve blood pressure control. They mention more aggressive lifestyle programs and/or other medication-strategies. In my opinion the current study does not totally support these conclusions. I do agree that lifestyle interventions are the most important measures in the diabetic population since they provide in blood pressure lowering as well as in better regulation of the diabetes (4). The study does not provide evidence that medication strategies add more to a better control of hypertension in a diabetic population than lifestyle changes.


    1. Iser BPM Claro RM Moura EC et al: Risk and protection factors for chronic non communicable disaese by telephone survey- Vigitel Brazil 2009. Rev Bras Epidemiol 2011; 14(3): 90-102
    2. Azadbakht L Fard NR Karimi M et al: Effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on cardiovascular risks among type 2 diabetic patients: a randomized crossover clinical trial. Diabetes Care 2011, 34:55¿7.
    3. Poortvliet RK Blom JW de Craen AJ et al: Low blood pressure predicts increased mortality in very old age even without heart failure: the Leiden 85-plus Study. Eur J Heart Fail. 2013 May;15(5):528-33
    4. Johnson M Jones R Freeman C Et al: Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence. Diabet. Med. 30, 3¿15 (2013)

    Competing interests

    no competing interest