non-pharmacological prevention and management of hypertension: a global perspective f.p.cappuccio md...

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

2

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

3


4


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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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)


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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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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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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‘Women sprinkling salt on their husbands to stimulate their sexual performance’

Anonymous woodcut

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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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Modest salt restriction in older people

Lancet 1997;350:850-4

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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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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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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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15


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)


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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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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20


Mean net changes in SBP and DBP

Whelton SP et al. Ann Int Med 2002;136:493-503

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22


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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25


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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“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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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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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

34


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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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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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

non-pharmacological prevention and management of hypertension: a global perspective f.p.cappuccio md...

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