Lifestyle Modifications for the Prevention and Management of

Hypertension

ANDREAS PITTARAS MD

Blood Pressure and CVD

• High BP is a strong, consistent and independent risk factor for CV events.

• The risk begins at BP 115/75 mm Hg and doubles with each incremental increase of 20/10 mm Hg.

•Vasan RS, et al. The Framingham Heart Study.JAMA 2002:287:1003-10 •Lewington S. Lancet 2002;360:1903-1913

JNC Goal:

Not Only Treat HTN, But Prevent it.

Does Increased Physical Activity Prevent or Attenuate

the Progression to HTN?

Physical Activity and BP

• Moderate increases in PA can prevent or at least attenuate the development of HTN.

• The RR for developing HTN is about 1.5 to 2.0 times higher in sedentary vs physically active individuals.

Staessen, et al., ’94; Sawada S, et al. ’93; Reaven et al., ‘91 Blair S, et al., ‘84 ; Paffenbarger et al., ‘83

115

125

135

145

Daytime 24-HR Nighttime

Ambulatory SBP and Fitness in Men

mm Hg

High-Fit

Mod-Fit

Low-FitN=407

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

68

74

80

86

92

Daytime 24-HR Nighttime

Ambulatory DBP and Fitness in Men

mm Hg

High-Fit

Mod-Fit

Low-FitN=407

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

120

130

140

150

Daytime 24-HR Nighttime

Ambulatory SBP and Fitness in Women

mm Hg

High-Fit

Mod-Fit

Low-FitN=243

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

70

75

80

85

90

Daytime 24-HR Nighttime

Ambulatory DBP and Fitness in Women

mm Hg

High-Fit

Mod-Fit

Low-FitN=243

Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

LVMI and Fitness in Pre-Hypertensives

48

41 41

30

40

50

LOW-FIT MOD-FIT HIGH-FIT

g/m2.7

Kokkinos, P, Pittaras A, Manolis T. Hypertension 2007; 49:1-7

N=790

The Role of Physical Activity in the Management of

Hypertension

Kokkinos P., et al. Cardiology Clinics 2001;19(3):507-516

Average Reduction in BP: Active: 10.5/7.6 mm Hg Controls: 3.8/1.3 mm Hg

Exercise and BP

• How Much Exercise for changes? (intensity, Duration, Frequency)

• How Intense Should Exercise Be?

• How Soon Do We See Results?

• How Long Do the Changes Last?

Exercise Intensity and BP Reduction

-25

-20

-15

-10

-5

0

mm Hg

Low Intensity (53% VO2 max)

High Intensity (73% VO2 max)

Hagberg J., et al. Am J Cardiol 1989;64:348-53

SBP DBP SBP DBP

-12

-10

-8

-6

-4

-2

0

mm Hg

Low Intensity (50% VO2 max)

High Intensity (75% VO2 max)

Matsusaki M, et al. Clin Exp Pharm & Physiol 1992;19:471-9

SBP DBPSBP

DBP

Exercise Intensity and BP Reduction

BP Changes with Exercise in pts with Severe Hypertension (Stage 2 & 3)

-10

-8

-6

-4

-2

0

mm Hg

16 weeks 32 weeks

Kokkinos P, Pittaras A.et al. N Engl J Med 1995;333:1462-7

SBP

SBP

DBP

DBP

Wall Thickness at Baseline & 16 weeks

13.3

12.3

14.9

14

11

12

13

14

15

PW IVS

mm

*

*

Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

Baseline

Baseline

16 Wks

16 Wks

LVMI at Baseline and 16 Weeks

163

143

135

141

147

153

159

165

*

* p<0.05

Baseline 16 weeks

g/m2

Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

Exercise Intensity Implications

• Low-to-moderate exercise intensities carry a relatively lower risk.

• Patients with more severe HTN and other risk factors can exercise safely.

• Patients are more likely to participate and sustain Lo-intensity exercise programs.

Exercise and BP Reduction

How Soon Should We Expect

To Observe Changes in BP?

Time Course for Exercise and BP Reductions

• Acute changes occur immediately after cessation of activity. They last about 2-12 hours.

• Chronic changes?

BP Changes with Exercise

-12

-8

-4

0mm Hg

SBP DBP

2 Weeks

16 Weeks

16 Weeks

2 Weeks

2 Weeks

Kokkinos P., Pittaras A et al. N Engl J Med 1995;333:1462-7

Exercise and BP Reduction

How Long Do

These Changes Last?

SBP Response to Training & Detraining

124

128

132

136

140

Baseline 16 Wks 32 Wks 7 Days 14 Days 21 Days

33% Reduction in Meds

mm Hg

Exercise Training

Clinical Significance of Exercise-Induced BP

Reduction

Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients

1

1.3

2

0.2

0.7

1.2

1.7

2.2

>8 5-8 MET <5

RR of DeathMyers J. et al., N Engl J Med 1002;346:793-801

Exercise Capacity and Mortality in HTN Pts (VAMC Data (n=4,397)

1

1.3

2.82.9

0

1

2

3

10+ METs 7.1-10 METs 5-7 METs <5 METs

RR of Death

Exercise Capacity and Mortality in HTN+DM: VAMC DATA

1

1.5

3.3

3.6

0

1

2

3

4

10+ METs 7.1-10 METs 5-7 METs <5 METs

RR of Death

Exercise Capacity and Mortality in HTN + Obesity: VAMC DATA

1

2.1

4.8 4.9

0

1

2

3

4

5

10+METs 7.1-10 METs 5-7 METs <5 METs

RR of Death

Survival and Fitness Levels for HTNs

>10 MET; n=968

7-10 MET; n=1563 5-7 MET; n=1310<5 MET; n=578

>10 MET; n=1,000

7-10 MET; n=1558

5-7 MET; n=1286

<5 MET; n=524Log Rank=222; p<0.001

N=4,368

Exercise Recommendations for BP Control

American College of Sports Medicine

F: Frequency: 3-6 times/wk

I: Intensity: Moderate (Brisk walk)

T: Time: 20-60 min/session.

May split sessions (AM/PM)

T: Type: Type of Exercise: Aerobic

Exercise Intensity for Health Benefits

PMHR: 60% - 70% >85%

METs: < 4 – 5 7 10 +

Fast walk Running

6 km/hr 10 km/hr

500 - 1000 3000 Kcal

Body Weight and BP

• A direct association between excess body wt and HTN regardless of age, gender & race.

• 4.5 kg reduction in wt resulted in reduced BP.

• 60% of pts remained normotensive without pharmacologic therapy (DISH Trial)

• Better control of BP achieved when Wt reduction added to antihypertensive therapy.

• Waist circumference <85 cm for women and <98 cm Men and BMI<27 are recommended.

Exercise for HTNsive, Obese Patients

• Likely to have multiple risk factors

• ETT strongly recommended

• Tailor exercise to patient needs/abilities.

• Frequency: 3-6 days/week

• Low intensity exercises (HR ~95-100 bpm)

• Initial duration of 10 min/day

• Two sessions (am/pm), 5 min/secs if needed)

• Increase by 2 min/wk- Aim: 100-200 min/wk

Dietary Factors and

Blood Pressure

Salt Reduction and Blood Pressure

• Historically, the limitation of salt in food has been the primary dietary approach in the control of HTN.

• Over 50 studies have been concluded. Recent Meta analysis revealed a reduction of 5/2.7 mm Hg in BP for a reduction of ~ 1.8 g/d in urinary sodium for HTN pts.

He FJ, et al. J Hum Hypertns. 2002;16:761-70

Foods and Blood Pressure• Calcium and Magnesium:

–Small reductions. Insufficient data to recommend supplementation.

• Potassium: –Meta-analysis (33 trials): a modest reduction (3/2 mm Hg) in HTN pts receiving potassium supplements. Effects more AA and those with high sodium intake.

• Fish Oil: Not routinely recommend

• Fiber: Insufficient data.

• High CHO Intake : –High sugar intake is shown to increase BP. More studies necessary

• High Protein Intake: –Some evidence of lower BP, but may be due to lower CHO

Comprehensive Dietary Approaches for BP Control

It is becoming more evident that diets low in salt and fat and rich in other minerals are more effective in lowering BP than any one element alone. Such diets include the DASH Diet and the Mediterranean diet.

DASH Trial and Blood Pressure

• Control Diet: – Low in fruits, veggies and dairy products

and typical fat content.– Potassium, magnesium, calcium at 25th

percentile of US consumption.

• Fruits & Vegetables Diet:– More fruits & Vegetables – Potassium, magnesium, calcium at 75%

of US consumption. – Fat content similar to Control Diet.

Appel L, et al. N Engl J Med 1997;336:1117-24

DASH Trial and Blood Pressure

• Combination Diet:– Rich in fruits, vegetables, fiber,

protein, and low-fat dairy products– Reduced amounts of total fat,

saturated fat and cholesterol.

• Sodium content of each diet was similar- approximately 3 g per day.

Appel L, et al. N Engl J Med 1997;336:1117-24

Weekly SBP in the DASH Trial

122

124

126

128

130

132

Base 1 2 3 4 5 6 7 & 8

mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24

Fruits + Vegetables

Control Group Diet

Fruits + Vegetables + Low Fat

Intervention Week

X=5.5 mm Hg

Weekly DBP in the DASH Trial

78

80

82

84

86

Base 1 2 3 4 5 6 7 & 8

mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24

Fruits + Vegetables + Low Fat

Intervention Week

X=3 mm Hg

Control Group Diet

Fruits + Vegetables

SBP Changes & Sodium in the DASH Trial

120

125

130

135

High-Salt Mod-Salt Low-Salt

mm Hg Sacks FM, et al. N Engl J Med 2001;344:3-10

Control Group Diet

DASH Diet

-5.9

-5.0

-2.2

DBP Changes & Sodium in the DASH Trial

75

80

85

High-Salt Mod-Salt Low-Salt

mm Hg

Control Group Diet

DASH Diet

Sacks FM, et al. N Engl J Med 2001;344:3-10

DASH Trial and Blood Pressure

• Compelling evidence that adequate intake of minerals should be the focus of dietary recommendations in the control of BP.

• The DASH Diet in combination with reduced salt intake optimizes BP control.

Alcohol Consumption and BP

Panagiotakos D. et al J Hypertens 2003;21:1-7

Lifestyle Interventions for BP Control: Conclusions

• High intake of fruits, vegetables, nuts and low-fat dairy products

• Reduce total fat, saturated fats, TC, • Restrict salt intake, but increase

calcium potassium and magnesium• Control body wt / Reduce body fat• Limit alcohol intake to <2 drinks/day• Brisk walk 3-6 times a week; 20-60

min per session (100-200 min/Wk).