Lifestyle Interventions for the Management of Hypertension

Louise Beesley

Hypertension Nurse Specialist

• Review current guidelines

• Review evidence base for key lifestyle interventions

• Explore less common lifestyle interventions

Lifestyle Interventions for the Management of Hypertension

So what do the guidelines say?

BHS Guidelines for the management of hypertension

BHS IV, 2004 and Update of the NICE Hypertension Guideline, 2006

Guidelines for management of hypertension: report of the fourth Working Party of the British Hypertension Society, 2004 BHS IV

B Williams et al: J Hum Hyp (2004); 18: 139-185.www.nice.org.uk/CG034NICEguideline

www.bhsoc.org

BHS IV

• A population strategy is required to

- prevent the rise in blood pressure with age

- reduce the need for antihypertensive drug therapy

- reduce the CVD burden

• Remember primary prevention

BHS IV

• Effective lifestyle modification may decrease BP as much as a single antihypertensive, combinations achieve more

• Lifestyle intervention may

-decrease pharmacological intervention

-enhance antihypertensive effect of drugs

-reduce need for multiple drug treatment

-positive influence on overall CVD risk

  

Target organ damageor

cardiovascular complicationsor

diabetesor

10 year CVD risk† 20%

>180/110 160 179100 109

140 15990 99

130 13985 89

<130/85

160/100 140 15990 99

<140/90

No target organ damageand

no cardiovascular complicationsand

no diabetesand

10 year CVD risk† <20%

* ** ***

Treat Treat Treat Observe, reassessCVD risk yearly

Reassessyearly

Reassessin 5 years

* Unless malignant phase of hypertensive emergency confirm over 1 2 weeks then treat** If cardiovascular complications, target organ damage or diabetes is present, confirm over 3 4 weeks then treat; if absent re-measure

weekly and treat if blood pressure persists at these levels over 4 12*** If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure

monthly and treat if these levels are maintained and if estimated 10 year CVD risk is 20%† Assessed with CVD risk chart

THRESHOLDS FOR INTERVENTIONInitial blood pressure (mmHg)

BHS IV

Lifestyle measures that lower blood pressure• Weight reduction• Limitation of alcohol consumption• Increased physical activity • Increased fruit and vegetable consumption • Reduced total fat and saturated fat intake

Measures to reduce cardiovascular disease risk • Cessation of smoking• Reduced total fat and saturated fat intake• Replacement of saturated fats with mono-unsaturated fats• Increased oily fish intake

NICE 2006

• Encourage use of salt substitutes

• Discourage excessive consumption of coffee and other caffeine rich products

• Tell patients about local initiatives that provide support and promote lifestyle change

• Consider relaxation therapies

• Lifestyle advice should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension

• Offer guidance and written or audiovisual information

BHS IV

Impact of lifestyle interventions on blood pressure

2-4mmHgAlcohol

4-9mmHgExercise

2-8 mmHgSalt

8-14 mmHgDietary

5-10 mmHg per 10kg weight lossWeight reduction

Expected systolic blood pressure reduction

Intervention

Lifestyle Interventions

The effect of weight loss on BP

• Estimated 24% of the population in the UK have a BMI > 30

• Neter et al (2003):1mmHg reduction in BP per 1kg weight loss

• Weight reduction has beneficial effects on associated risk factors i.e. insulin resistance, diabetes, dyslipidaemia and LVH

Clinic measurements

• Weight

• Height

• BMI

• Waist measurement – midway between lower rib margin and the ileac crest

BMI and Waist measurements

BMI Category

<20 Underweight

20-24.9 Normal

25-29.9 Overweight

30-39.9 Obese

>40 Severely Obese

Abdominal obesity

Men >102cmWomen >88cm

Indio Asia decentMen >90cmWomen >80cm

JBS Guidelines 2005

Referral pathway

• Exercise on prescription

• Dietician

• “Weight Watchers”

• Obesity clinic

• Surgical Intervention

Long term benefits of weight reduction

• He et al. (2000) “Beneficial effects are still evident 7 years after study ended.”

• n= 208 high impact weight reduction advice and support• 7 years later 181 brought back• Incidence of hypertension:

19% in weight loss group40% control group

• Effect, despite being an equal amount of weight gain in both groups over the period

Dietary interventions and BP

DASH – Dietary approach to stop hypertension diet (2000)Participants with mild hypertension had approx. 11.4mmHg

reduction in systolic BP compared to control diet• Combination of a Mediterranean diet with low fat dairy

products • Low fat, high fibre including increased amounts of

potassium, calcium, and magnesium• Effects potentiated by salt restriction• Diet better tolerated than salt restrictions

5 a day (or 7-9 if possible!)

• 1 portion of fruit or vegetable represents 80g i.e 1 apple, 1 orange, 1 banana, 2 satsumas, 2 plums, 3 heaped tbsp peas or carrots, 1 bowl of mixed salad

• 1 glass of 100% fruit juice can replace 1 portion• 1 portion of fruit and vegetables a day lowers CVD risk by

4% (Joshipura et al. 2001)• Beneficial effects due to array of compound i.e. vitamins

and minerals, phytochemicals, antioxidants• Individual compounds not enough – supplements

containing isolated compound do not have same effect – may cause more harm than good

Physical activity and BP

• Aerobic endurance based activities reduce resting BP in adults with normal BP and in those with hypertension

• Places demands on the cardiovascular system• Reductions in BP last for up to 22hrs after

exercise (ACSM, 2004)• BP reductions are independent of weight loss

(Whelton et al. 2002)

Adapted from EUROACTION data BJC Sept 2006

Exercise training in the management of and treatment of hypertension

2.44.66,805105Dickenson et al. 2006

2.43.03,93672Cornelissen and Fagard 2005

2.54.02,41954Whelton et al. 2002

2.43.42,67444Fagard 2001

3.14.71,55329Halbert et al.20 1997

Decrease

in DBP

(mmHg)

Decrease

in SBP

(mmHg)

Number of subjects

RCTs included

Meta-analysis

Exercise Recommendations

• Frequency –x5, preferably all days of the week• Intensity – moderate • Time – 30 minutes or more of continuous activity,

alternatively 3 bouts of no less than 10 minutes accumulated during the day

• Type – aerobic exercise using large muscle groups• Caution if systolic >160mmHg and/or diastolic

>110mmHg

Alcohol and BP

• Association seen as long ago as 1917• Study of trench soldiers

“tres grands buveurs” – hypertensive“sobres” – normotensive

• Klatsky (1977) n= 84,000 men3 or more drinks per day – dose dependent relationship

• Beevers (1984) direct pressor effect of alcohol established –observed alcohol consumption and withdrawal

• Reduction in alcohol consumption may reduce BP by an average of 3/2 mmHg (Xin 2001)• Daily drinking and on empty stomach associated

with higher BP• There should be 2 alcohol free days per week• There are probably no safe alcohol limits ≤ 14 units per week for women and ≤ 21units per

week for men• Binge drinking is now defined as >3 units/day• ?? Cardioprotective properties……Jackson 2005

argued may be due to confounding

• Assess number of units per week

• Number of alcohol free days

• Binge drinking

• GGT

• 125ml wine

• 1 pub shot of spirit (35ml)

• ½ pint lager / beer / cider

The Times Dec 2006

Wine strength

11.110.59.69.08.47.56.9750ml bottle

3.73.53.23.02.82.52.3250ml

2.62.52.32.11.91.81.6175ml

1.81.71.61.51.41.31.1125ml

15%14%13%12%11%10%9%Glass size

Smoking and BP

• Cigarette smoking does not appear to be associated with hypertension

• BP does rise acutely during smoking leading to underestimation of BP in regular smokers

• Extensive observational data show that smoking has a graded adverse effect on risk of cardiovascular complications

• Use of nicotine replacement therapies is safe in hypertensives and doubles smoking cessation rates

• Assess smoking history- smoker / non smoker- how long given up- number of years / pack years- method of smoking- previous attempts at cessation- NRT- desire to give up

• Smoking cessation clinic / NRT

Effect on CVD risk

• Age 51• Gender male• SBP 156• Smoker no• Hx diabetes no• LVH no• Cholesterol 5.1• HDL 1.2

CVD RISK 16 %

• Age 51• Gender male• SBP 156• Smoker yes• Hx diabetes no• LVH no• Cholesterol 5.1• HDL 1.2

CVD RISK 28 %

Effect of Salt on Blood pressure

• Recommended salt intake is 5g/day• Estimated that average intake is 9.5g/day• A max of 25% comes from adding at table or cooking• Na value x 2.5 to gain NaCl value• DASH Sodium - reduction in blood pressure with lower

sodium intake – direct relationship• Few observational studies and virtually no trial data exist

on the effect of sodium intake on subsequent cardiovascular disease

Sacks et al. N Eng J of Med 2001;344:3-10

Cook, N. R et al. BMJ 2007;334:885

Fig 2 Cumulative incidence of cardiovascular disease (CVD) by sodium intervention group in

TOHP I and II, adjusted for age, sex, and clinic

Cook, N. R et al. BMJ 2007;334:885

Fig 3 Total mortality by sodium intervention group in TOHP I and II, adjusted for age, sex, and clinic

< 5 grams?!!!• Breakfast

30g cornflakes with skimmed milk and red berries1 Slice brown bread with low fat spread

• Lunch1 tortilla wrap 2 slices “carvery ham”1 packet popular brand crispsApple

• Evening mealHealthy options lasagne, side salad, jacket potatoYoghurt and strawberries

• Snack2 digestive biscuits, banana

1g0.5g

0.8g 2g0.5g

3.5g

1g

TOTAL 9.3g

Salt Friendly???

• Low

Fresh fruit, vegetables

Pulses, lentils

Meat, chicken

Unsalted nuts

Rice

Pasta

Egg noodles

Chicken

Egg

<0.25g salt per 100g of food - low

0.25 – 1.25g salt per 100g of food moderate

>1.25g salt per 100g food heavily salted

• HighCanned produceProcessed meatsReady mealsPacket foodBreadSome cerealsCheeseBottle sauces i.e. ketchup,soyBacon/ sausage/ beefburgersPates/ smoked or tinned fish

www.losalt.com

Salt substitutes

• Losalt1 gram contains:131mg of Sodium346mg of Potassium

• 800mg of Potassium in the average daily diet from salt substitute.

• Combined multisource daily intake is approx 3000mg potassium

• Guidance on high Potassium intake:daily range: 1600mg to 5900mgharmful range: 17,600mg (50g of LoSalt)

Effects of other minerals

• Potassium: ↓ BP 4.4/2.5 mmHg in hypertensive patients

↓ BP 1.8/1.0 mmHg in normotensives

• Observational studies show links to calcium and magnesium

• Less consistent evidence supporting omega -3 fatty acids, vits C, E and B6, folate and flavenoids.

• NICE/BHS ‘do not give supplements’

Caffeine rich products and BP

• Potent physiological effects

• Caffeine given as tablets resulted in BP elevations ( x4 greater than for caffeinated coffee) Noordzij et al. 2004

• Winkelmayer et al. (2005) found association with caffeinated cola drinks and risk of hypertension (but not with caffeinated coffee)

• Caffeine intake may only be a risk factor in individuals who are genetically slow caffeine metabolisers (Cornelis,2005)

Hamer,M (2006) Journal of human hypertension.20, 909-912

Coffee

• Effect on health remains equivocal

• 2 prospective cohort studies give conflicting opinions

- Winkelmayer et al. 2005 showed no relationship between coffee intake and incidence of hypertension (n=155,594 US women over 12 years)

- Klag et al. 2002 – John Hopkins precursor study

demonstrated a 0.19 and 0.29 mmHg rise in systolic and diastolic respectively (n=1017 men consuming 1 cup of coffee per day

Hamer,M (2006) Journal of human hypertension. 20, 909-912.

• ?? Beneficial effects

• ? Anti-oxidant properties

• ? Anti-inflammatory effects

• ? Inhibit harmful effects of other dietary components i.e. inhibition of alcohol-related hypertensive effects by lowering serum GGT

Dietary peptides and BP

• Certain dietary peptides shown to lower BP• Peptides are now being incorporated into food

products• Derived from the milk product casein either

through fermentation or enzymatic hydrolysis• IPP (transpeptides isoleucine proline-proline) and VPP (valine proline-

proline) inhibit angiotensin converting enzyme• Dose dependent response in reduction of both

systolic and diastolic BP

Stress management

• Often quoted as cause of hypertension – no evidence to support this

• Stress and anxiety cause a temporary rise in BP, but when relaxed will fall to normal levels

Relaxation Therapies

• Stress management• Meditation• Cognitive therapies• Muscle relaxation• Biofeedback

Shown to result in short term reductions in BP, but the interventions studied have been so varied, it is difficult to be prescriptive

Bandolier Oct 2002

Changes (start-end) in systolic blood pressure for stress management interventions

Resperate

• “relaxes constricted blood vessels to lower BP”

• 15mins paced breathing few times per week leads to vasodilation of vascular smooth muscle

Herbal remedies

• Limited and inadequate evidence available to support the use of garlic, herbal and complimentary medicines to lower BP

- potassium supplement- dandelion leaf (diuretic)- hawthorn (vasodilator)- linden (vasospasm)- ginkgo biloba (peripheral blood flow)- mistletoe (vasodilator)- ginger (Mg2+,Ca2+,K+)

Motivation, Motivation, Motivation

• NICE 2006

“education alone is unlikely to be effective”

• Referral to outside agencies

• Support and encouragement

• Achievable and sustainable

Outcome of annual review of borderline hypertensives

42%

58%

Medicated

Non Medicated