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Non-pharmacological prevention and management of hypertension: a global perspective

Non-pharmacological prevention and management of hypertension: a global perspective. F.P.Cappuccio MD MSc FRCP MFPH Cephalon Chair of Cardiovascular Medicine & Epidemiology Warwick Medical School. Non-pharmacological prevention and treatment of raised blood pressure. Why ? Population effect

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Non-pharmacological prevention and management of hypertension: a global perspective

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  1. Non-pharmacological prevention and management of hypertension: a global perspective F.P.Cappuccio MD MSc FRCP MFPH Cephalon Chair of Cardiovascular Medicine & Epidemiology Warwick Medical School

  2. 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

  3. Untreated patients Wing (1998)a Blumenthal (2000)a Fagerberg (1984) MacMahon (1985) Wing (1998)b Fortmann (1988)a Anderssen (1995)a Croft (1986) Blumenthal (2000)b Gordon (1997) Anderssen (1991) Anonymous (1990) Stevens (1993) Anderssen (1995)b Fortmann (1988)b Anonymous (1997) Masuo (2002)a Langford (1991) He (2000) Oberman (1990) Haynes (1984) Stamler (1989) Blumenthal (2000)c Anderssen (1995)c Masuo (2002)b Wing (1998)c Combined -30 -20 -10 0 10 Change in systolic blood pressure (mm Hg) Neter et al. Hypertension.2003;42:878-84

  4. Treated patients Singh (1990) Reisin (1978) Ard (2000) Jalkanen (1991) Lalonde (2002)a Singh (1995) Whelton (1998) Lalonde (2002)b Combined -30 -20 -10 0 10 Change in systolic blood pressure (mm Hg) Neter et al. Hypertension.2003;42:878-84

  5. 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

  6. 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

  7. Anonymous woodcut ‘Women sprinkling salt on their husbands to stimulate their sexual performance’

  8. DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND LONG-TERM EFFECTS OF SODIUM RESTRICTION IN ESSENTIAL HYPERTENSION Lancet 1989; ii:1244-7

  9. Modest salt restriction in older people Lancet 1997;350:850-4

  10. -5.0 mmHg -2.0 mmHg Dietary Sodium Reduction and Blood Pressure 17 trials in hypertensives (n=734) 11 trials in normotensives (n=2,220) >4 wks duration Reduction in sodium ~80 mmol/day J Hum Hypert 2002;16:761-70

  11. Systolic BP (mmHg) Diastolic BP (mmHg) 95th 95th 80th 80th 50th 50th 20th 20th 5th 5th 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

  12. Normotensive Hypertensive <140 mmol/d 140-164 mmol/d >=165 mmol/d -12 -10 -8 -6 -4 -2 0 2 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

  13. 132 Control 131 130 129 Fruit & Veg 128 SBP (mmHg) 127 Combination 126 125 124 123 3 5 1 2 4 6 7 & 8 Baseline weeks 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

  14. Systolic blood pressure reduction following the DASH diet and a reduction of salt intake 136 3.5 134 3 132 Systolic blood pressure (mmHg) 2.5 g of sodium consumed per day 130 2 128 1.5 126 1 124 0.5 122 120 0 High Intermediate Low 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. -2.1 (-3.4 to –0.8) -4.6 (-5.9 to –3.2) -1.3 (-2.6 to 0.0) -1.7 (-3.0 to –0.4) Sacks et al. N Eng J Med. 2001;344:3-10.

  15. Mean net changes in SBP and DBP Whelton SP et al. Ann Int Med 2002;136:493-503

  16. Lang et al, 1995 Cushman et al, 1998 Wallace et al, 1988 Maheswaran et al, 1992 Ueshima et al, 1987 Systolic blood pressure Ueshima et al, 1993 Rakic et al, 1981 Rakic et al, 1982 Puddey et al, 1985 Kawano et al, 1998 Parker et al, 1990 Puddey et al, 1992 Cox et al, 1993 Puddey et al, 1986 Howes and Reid, 1986 76% Combined Lang et al, 1995 Cushman et al, 1998 Maheswaran et al, 1992 Ueshima et al, 1987 Diastolic blood pressure Ueshima et al, 1993 Rakic et al, 1981 Rakic et al, 1982 Puddey et al, 1985 Kawano et al, 1998 Parker et al, 1990 Puddey et al, 1992 Cox et al, 1993 Puddey et al, 1986 Howes and Reid, 1986 76% Combined 0 -15 -10 -5 5 10 Reduction in blood pressure (mm Hg) Reduction in self-reported daily consumption of alcohol 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

  17. 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

  18. Selected leading causes of death worldwide in 1990 3M (~70%) in developing countries Number of deaths (million) Lancet 1997;349:1269-76

  19. Mortality due to leading global risk factors Ezzati M et al. Lancet 2002;360:1347-60

  20. Stroke mortality in urban and rural Tanzania Lancet 2001;355:1684-7

  21. Low smoking, moderate fat and salt intake High smoking, fat and salt intake Moderate smoking, moderate fat but high salt intake Increasing levels of acculturation, urbanization and affluence Stages in the epidemiological transition of C.V.D. Cappuccio FP. Int J Epidemiol 2004; 33:387-8

  22. “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

  23. Cappuccio FP; Unpublished

  24. Prevalence of detection, management and control of hypertension in Ashanti P=0.007 P=0.06 P=0.05 Cappuccio FP et al. Hypertension 2004; 43: 1017-22

  25. Community dietary salt reduction in Kumasi 6.4 (0.5 to12.3) 4.5 (-0.3 to 9.3) 44 (22 to 66) BASELINE 4 WEEKS 20 farmers Cappuccio FP et al. Lancet 2000;356:677-8

  26. 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

  27. Risk of stroke attributable to high blood pressure ~40% ~78%

  28. 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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