Non-pharmacological prevention and management of hypertension:
a global perspective
F.P.Cappuccio MD MSc FRCP MFPHCephalon Chair of Cardiovascular Medicine & Epidemiology
Warwick Medical School
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Non-pharmacological prevention and treatment of raised blood pressure• Why ?
– Population effect– High risk patient
• When ?– Primary prevention– Disease management
• What?– Weight reduction– Reduction in sodium (salt) intake– High potassium diet– Regular dynamic exercise– Moderate alcohol consumption
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Untreated patients
-30 -20 -10 0 10
Combined
Wing (1998)c Masuo (2002)b
Anderssen (1995)c Blumenthal (2000)c
Stamler (1989) Haynes (1984)
Oberman (1990) He (2000)
Langford (1991) Masuo (2002)a
Anonymous (1997) Fortmann (1988)b
Anderssen (1995)b Stevens (1993)
Anonymous (1990) Anderssen (1991)
Gordon (1997) Blumenthal (2000)b
Croft (1986) Anderssen (1995)a Fortmann (1988)a
Wing (1998)b MacMahon (1985) Fagerberg (1984)
Blumenthal (2000)a Wing (1998)a
Change in systolic blood pressure (mm Hg)
Systolic blood pressure change in randomized controlled trials of weight reduction in function of whether or not the patients follow an antihypertensive treatment.
Neter et al. Hypertension.2003;42:878-84
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Treated patients
-30 -20 -10 0 10
Combined
Lalonde (2002)b
Whelton (1998)
Singh (1995)
Lalonde (2002)a
Jalkanen (1991)
Ard (2000)
Reisin (1978)
Singh (1990)
Change in systolic blood pressure (mm Hg)
Systolic blood pressure change in randomised controlled trials of weight reduction in function of whether or not the patients follow an antihypertensive treatment.
Neter et al. Hypertension.2003;42:878-84
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Trial Of Non-pharmacological intervention in the Elderly (TONE): weight (-3.5kg) and sodium (-40mmol/d) reductions in elderly patients (60-80 yrs) ►BP reduction (-30%)
Diet, Exercise and Weight loss Intervention Trial (DEW-IT): DASH-diet + fitness program ►-4.9kg and -12/-6mmHg
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Possible mechanisms
• Inhibition of an overactive R.A.A. system in obese subjects
• Stimulation of the natriuretic peptides system with natriuresis and vasodilation
• Reduction of the activity of the S.N.S.
• Reduction in insulin resistance and hyperinsulinaemia
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
‘Women sprinkling salt on their husbands to stimulate their sexual performance’
Anonymous woodcut
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND LONG-TERM EFFECTS OF SODIUM RESTRICTION IN ESSENTIAL HYPERTENSION
Lancet 1989; ii:1244-7
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Modest salt restriction in older people
Lancet 1997;350:850-4
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
J Hum Hypert 2002;16:761-70
17 trials in hypertensives (n=734)11 trials in normotensives (n=2,220)>4 wks durationReduction in sodium ~80 mmol/day
Dietary Sodium Reduction and Blood Pressure
-5.0 mmHg
-2.0 mmHg
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
0
2
4
6
8
10
12
14
16
15-19 20-29 30-39 40-49 50-59 60-69
0
1
2
3
4
5
6
7
8
15-19 20-29 30-39 40-49 50-59 60-69
95th
80th
50th
20th
5th
95th
80th
50th
20th
5th
Systolic BP (mmHg) Diastolic BP (mmHg)
Age (years) Age (years)
Estimated changes in systolic (left) and diastolic (right) blood pressures for 100 mmol per day change in sodium intake by centiles of the blood
pressure distribution
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
How to reduce salt intake: a practical advice Target daily salt intake should not exceed 5 grams per day
1. Never add salt to a meal You shouldn’t Instead - Use rock salt or sea salt. - Add sauces
Use pepper, garlic, lemon, and herbs.
2. Do not add salt to the cooking You shouldn’t Instead - Use stock cubes, gravy browning, soy
sauce, or salted dry fish. - Use curry powders and prepared
mustards
Try other flavourings! - Any herbs, spices. - Lemon or lime. Vinegar - Onions, garlic, ginger, and chillies.
3. Avoid manufactured or processed foods with added salt Food labelling Salt is sodium chloride. At the moment most food labels only report sodium as grams per 100 grams of food. To convert to salt multiply by 2.5.
1 gram of sodium per 100 grams of food is the equivalent to the saltiness of seawater! Beware Ideally - Most breads, Many cereals - All ready soups and meals, processed
meats, take-away pizzas, Chinese take-away.
- Only chose food items with no more than 0.3 grams of sodium per 100 grams of food
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Normotensive
Hypertensive
<140 mmol/d
140-164 mmol/d
>=165 mmol/d
20-2-4-6-8-10-12
Difference in systolic blood pressure after potassium supplementation
as function of the hypertension status and urinary sodium (marker of salt intake)
Change in systolic blood pressure (mm Hg)
The blood pressure lowering effect of potassium appears to be higher in hypertensives than normotensives and enhanced in patients with a high sodium intake. Potassium supplementation should be considered for the non-pharmacological treatment of hypertension, especially for those unable to reduce their salt intake.
Whelton P et al. JAMA 1997;277:1624-32
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Foods rich in potassium classified by descending content Foods with 5 mmol or more of elemental potassium per 100g.
Fresh fruits Pulses (legumes) Vegetables Banana Bean (dry) Mushroom Apricot Broad bean (dry) Potatoes Plum Chickpeas (dry) Spinach Cherries Lentils (dry) Artichoke Grapefruit Broad bean (fresh) Broccoli Grapes Cauliflower Oranges Chicory Peaches Asparagus Cabbage Fennel Lettuce Prickly lettuce String beans Raw tomatoes Turnip
Other foods: 2 to 5 mmol of elemental potassium per 100g. Fresh fruits Pulses (legumes) Vegetables Orange juice Canned beans Carrots Pear Canned lentils Green tomatoes Apple Peas (fresh) Aubergine Peas (frozen) Radicchio Green peppers Peppers
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
D.A.S.H. diet• High fruit & vegetables• Low fat dairy products• Whole grains & Nuts• Poultry & Fish• Little red meat, sweets,
sugar-containing drinks• Reduced total and
saturated fat• Reduced cholesterol N Engl J Med 1997;336:1117-24
123
124
125
126
127
128
129
130
131
132
Baseline 1 2 3 4 5 6
7 & 8
weeksSB
P (m
mH
g)
Control
Fruit & Veg
Combination
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120
122
124
126
128
130
132
134
136
High Intermediate Low
Syst
olic
blo
od p
ress
ure
(mm
Hg)
0
0.5
1
1.5
2
2.5
3
3.5 g of sodium consum
ed per day
Level of sodium consumption Control Diet DASH Diet
The reduction in salt consumption is a valuable non pharmacological measure to reduce blood pressure; its combination with the DASH diet is additive.
Systolic blood pressure reduction following the DASH diet and a reduction of salt intake
Sacks et al. N Eng J Med. 2001;344:3-10.
-2.1(-3.4 to –0.8)
-1.3 (-2.6 to 0.0)
-4.6(-5.9 to –3.2)
-1.7 (-3.0 to –0.4)
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Mean net changes in SBP and DBP
Whelton SP et al. Ann Int Med 2002;136:493-503
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76%
76%
Lang et al, 1995Cushman et al, 1998Wallace et al, 1988
Maheswaran et al, 1992Ueshima et al, 1987Ueshima et al, 1993
Rakic et al, 1981Rakic et al, 1982
Puddey et al, 1985Kawano et al, 1998
Parker et al, 1990Puddey et al, 1992
Cox et al, 1993Puddey et al, 1986
Howes and Reid, 1986
Combined
Lang et al, 1995Cushman et al, 1998
Maheswaran et al, 1992Ueshima et al, 1987Ueshima et al, 1993
Rakic et al, 1981Rakic et al, 1982
Puddey et al, 1985Kawano et al, 1998
Parker et al, 1990Puddey et al, 1992
Cox et al, 1993Puddey et al, 1986
Howes and Reid, 1986
Combined-15 -10 -5 0 5 10
Reduction in blood pressure (mm Hg)
Reduction in self-reported daily consumption of alcohol
Systolic blood pressure
Diastolic blood pressure
Effect of alcohol reduction on systolic and diastolic blood pressure
There is a dose-response relation between the reduction in blood pressure following a reduction in alcohol intake. Xin et al. Hypertension.2001;38:1112-7
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PREMIER Clinical Trial• 4 centres RCT• 810 adults• Women 62%• African-Americans 34%• BP 120-159 / 80-95 mmHg• Not on therapy• Treatment arms:
– Advice only (n=273)– Established recommend. (n=268)– Established plus DASH (n=269)
• Duration: 6 months
JAMA 2003; 289: 2083-93
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Selected leading causes of death worldwide in 1990
0 1 2 3 4 5 6 7
HIV
Breast Ca
M alnutrition
Bowel Ca
Liver Ca
War
Drowning
Tetanus
Violence
Diabetes
Stomach Ca
Cirrhosis
M alaria
Respiratory Ca
Road accidents
M easles
TB
COAD
Diarrhoea
Respiratory infections
Cerebrovascular Disease
Ischaemic Heart Disease
Number of deaths (million)
Lancet 1997;349:1269-76
3M (~70%
)
in developing
countries
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Ezzati M et al. Lancet 2002;360:1347-60
Mortality due to leading global risk factors
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Stroke mortality in urban and rural Tanzania
Lancet 2001;355:1684-7
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0
0.5
1
1 .5
2
2 .5
3
3 .5
4
4 .5
1 2 3 4 5 6
Stage
Car
diov
ascu
lar
Dis
ease
Hypertensive Atherosclerotic
High smoking, fat and salt
intake
Low smoking, moderate fat and salt intake
Moderate smoking, moderate fat
but high salt intake
Increasing levels of acculturation, urbanization and affluence
Cappuccio FP. Int J Epidemiol 2004; 33:387-8
Stages in the epidemiological transition of C.V.D.
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
“More than a quarter of the world’s adult population – totalling nearly one billion (640 million in developing countries) – had hypertension in 2,000, and … this proportion will increase to 29% - 1.56 billion – by 2,025.”
Kearney PM et al. Lancet 2005;365:217-23
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Cappuccio FP; Unpublished
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
P=0.007P=0.06
P=0.05
Prevalence of detection, management and control of hypertension in Ashanti
Cappuccio FP et al. Hypertension 2004; 43: 1017-22
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
77.5
80
82.5
85
87.5
90
Dia
sto
lic B
P (
mm
Hg)
BASELINE AFTER FOUR WEEKS
0
50
100
150
Urin
ary S
odiu
m (
mm
ol/
24h)
125
130
135
140
Systo
lic B
P (
mm
Hg)
Community
dietary salt
reduction in
Kumasi
Cappuccio FP et al. Lancet 2000;356:677-8
BASELINE 4 WEEKS
6.4 (0.5 to12.3)
4.5 (-0.3 to 9.3)
44 (22 to 66)
20 farmers
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Reduction in systolic blood pressure achieved by two pilot trials of salt reduction in sub-Saharan Africa
Cappuccio FP et al. Lancet 2000;356:677-8 Adeyemo AA et al. Ethn Dis 2002;12: 207-11
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Risk of stroke attributable to high blood pressure
0%
20%
40%
60%
80%
100%
Developedregions
Developingcountries
Smoking BP AF Others
~40%
~78%
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3rd Baltic-Nordic Meeting on HypertensionVilnius, October 2005
Conclusions• Lifestyle modifications are effective measures in
the prevention and management of hypertension across the world
• The BHS IV Guidelines suggest:– Maintain normal weight for adults (BMI 20-25 kg/m2)– Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4g
Na+/day)– Limit alcohol consumption to <3 units/day for men and
<2 units/day for women– Engage in regular aerobic physical exercise (brisk walking rather
than weightlifting) for >30 min per day– Consume at least five portions/day of fresh fruit and vegetables– Reduce the intake of total and saturated fat
• Necessary involvement of consumers, industry and governments
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