Non-pharmacological lowering of BP

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Non-pharmacological lowering of BP

• Simon Thom

GP cardiovascular disease course, 8 May 2008
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The 10 leading causes of death by broad income
group, 2005 estimates
WHO Fact sheet N 310 / February 2007
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Medecins Sans Frontieres

• 15 of the worlds population consumes over 90
  of the worlds pharmaceuticals.
• Tajikistan Hydrochlorthiazide 25mg (generic)
  33.5x more expensive than international standard
  cost one days treatment costs one days wages.

https//www2.essex.ac.uk/human_rights_centre/rth/
Gelders S. et al. Price, availability
affordability an international comparison of
chronic disease medicines. WHO
http//mednet3.who.int/medprices/
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Number of people with hypertension aged 20 years
and older by world region and sex in 2000 (upper)
and 2025 (lower)
Kearney PM et al. Lancet 2005 365 21723
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Distribution of attributable burden by exposure
levels
Blood pressure Cholesterol
Body mass index
Hypertension
?cholesterol
Obesity
Attributable DALYs (000s)
Exposure levels
Commonly used threshold values for current
definitions
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Cumulative incidence of cardiovascular events in
men with high normal, normal and optimal blood
pressure
High normal
Cumulative Incidence ()
Normal
Optimal
Time (years)
Vasan R et al. N Engl J Med 20013451291-1297
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KaplanMeier curves for the transition from
pre-hypertension to hypertension in the Trial of
Preventing Hypertension (TROPHY).
Julius S et al. 2006 N Engl J Med 2006 354
16851697
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Lifestyle interventionsBHS Guidelines

• Measures that lower blood pressure
• Weight reduction
• Reduced salt intake
• Limitation of alcohol consumption
• Physical exercise
• Increased fruit vegetable consumption
• Reduced total fat saturated fat intake
• Measures to reduce cardiovascular risk
• Stop smoking
• Replace saturated fat with poly-
  mono-unsaturated fats
• Increase oily fish consumption
• Reduce total fat intake

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Mortality, due to leading global risk factors
Ezzati M. et al. http//www.dcp2.org/pubs/GBD/4/Fi
gure/4.1 Lopez AD. et al. Lancet 2006 3671747-17
57
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Time trend in percentages of obese US children
teenagers
Nestle M. NEJM 2006 354 2527 McGinnis JM. Nat
Acad Press 2006
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• Rapid emergence of obesity
• within a generation
• acquired, not genetic

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Prevalence of inactivity among adults, England
1998
Men Women
Achieving lt30 mins mod exercise / week
Age
Health Survey for England
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Adjusted ORs for obesity by quintiles of
objectively measured minutes of moderate
vigorous activity.
2,878 12-year-old girls from the Avon
Longitudinal Study of Parents and Children
Odds Ratio
Model 4 - maximally adjusted obesity (adjusted
for age, height, height sq) regressed on
quintiles of MVPA, maternal education, lowest
social class, birthweight, gestational age,
smoking in pregnancy, obesity of mother, sleep
pattern, TV viewing, pubertal stage.
Ness AR. et al. PLoS Med. 2007 March 4(3) e97
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Alcohol

• 200,000 alcohol related deaths / year in EU
• 3rd leading risk factor for death disability
• Accounts for 25 of young male deaths 10 of
  young female deaths
• Social cost 200 billion / year

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Alcohol increases blood pressurePrevalence of
hypertension (gt150/100) amongst French soldiers
stratified by alcohol intake
Dr C Lian, French army physician Bull Acad Med
1915 74 525-528
hypertensive
Sobres
Moyens buveurs
Grands buveurs
Tres grands buveurs
Sobres lt 1 litre wine / day Moyens buveurs 1
- 1.5 litres wine / day Grands buveurs 2 - 2.5
litres wine / day 2 aperitifs Tres grands
buveurs gt 3 litres wine / day 4 - 6 aperitfis
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Adjusted ORs for incident MI (men) by average
daily alcohol intake (A), frequency of alcohol
intake (B)
Adjusted age, BMI, smoking, parental history MI,
DM, hypertension, high cholesterol, exercise,
aspirin, vit E supps, energy intake, fats,
folate, fiber.
Further adjustment for HDL-C, fibrinogen, HBA1c
accounted for remainder
Mukamal KJ et al. Circulation 2005 112 1406
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Alcohol mortality among men in American Cancer
Society prospective study
Boffetta P. Epidemiology 1990 1 342
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Salt

• The average UK salt consumption is 9 gm / day
• Dietary requirement is 1.4 gm / day

Food groups contributing the most salt to our
diet

• 35 from cereal cereal products e.g. bread,
  breakfast cereals, 'morning goods'
• 26 from meat meat products e.g. bacon ham,
  burgers, sausages
• 8 from milk milk products e.g. milk, cheese

Consensus Action on Salt Health http//www.actio
nonsalt.org.uk/index.htm
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Recommendations
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Lifestyle measures BHS IV

• Maintain normal weight for adults (BMI 20-25
  kg/m2)
• Reduce salt intake to lt100 mmol/day (lt6g NaCl or
  lt2.4 g 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 weight lifting) for
  ?30 minutes per day, ideally on most of days of
  the week but at least on three days of the week
• Consume at least five portions/day of fresh fruit
  and vegetables
• Reduce the intake of total and saturated fat

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WCRF recommendations for cancer prevention

• Be as lean as possible without becoming
  underweight. 
• Be physically active for at least 30 minutes
  every day.
• Avoid sugary drinks. Limit consumption of
  energy-dense foods (particularly processed foods
  high in added sugar, or low in fibre, or high in
  fat).
• Eat more of a variety of vegetables, fruits,
  whole grains, pulses such as beans.
• Limit consumption of red meats (such as beef,
  pork lamb) avoid processed meats.
• If consumed at all, limit alcoholic drinks to 2
  for men 1 for women a day.
• Limit consumption of salty foods foods
  processed with salt.
• Don't use supplements to protect against cancer.
• Special Population Recommendations
• It is best for mothers to breastfeed exclusively
  for up to 6 months then add other liquids
  foods.
• After treatment, cancer survivors should follow
  the recommendations for cancer prevention.
• Do not smoke or chew tobacco.

Food, nutrition, physical activity the
prevention of cancer a global perspective www.die
tandcancerreport.org
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Expected benefits
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The effect of lifestyle modifications on BP
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The effect on systolic BP of reduced sodium
intake and the DASH Diet.
412 subjects - normotensive hypertensive -
randomised to diet rich in veg low fat 3
levels of salt intake. Greatest BP reduction seen
in DASH group -8 to -14 mmHg
Sacks FM et al. NEJM 2001 344 3-10
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Reduction in dietary sodium intake prevents CVD
Total mortality by sodium intervention group in
TOHP I II, adjusted for age, sex clinic
Cumulative incidence of CVD by sodium
intervention group in TOHP I II, adjusted for
age, sex clinic
Cook NR et al. BMJ 2007 334 885
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Potassium and BP
1. Clinical trials, epidemiological and
laboratory studies suggest ? dietary K intake
? ? B.P. levels - 3 / 2 in meta-analysis Wh
elton P, JAMA 1997 2771624 2. The hypotensive
effect of K may be dependent upon a high Na
intake.
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Increased consumption of fruit vegetables is
related to a reduced risk of CHD meta-analysis
of cohort studies
RR 95 CI of CHD for fruit vegetable intake
of 35 servings/day gt5 servings/day compared
with lt3 servings/day. The size of the square is
proportional to the weight of each study in the
meta-analysis.
He FJ et al. J Human Hyp 2007 21 717
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Alcohol and BP size of the effect
Whitehall Study
32gm alcohol /day ? ? by 5/2 mmHg
Kaiser Permanente (white males)
? 6 drinks/day doubles hypertension rate
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Effect of one years regular exercise on blood
pressure
-20/15
Meta-analysis, 106 RCTs (6805 subjects) - 4.6 /
2.4 Dickenson et al. 2006
Jennings G et al. J Hypertension 1986 4(6) 659
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Physical fitness predicts mortality - all causes,
1960 Norwegian men
10
Quartile 1
Quartile 2
8
6
Quartile 3
Cumulative mortality,
4
Quartile 4
2
2
4
6
8
10
12
14
16
Years of follow-up
Sandvik L, NEJM 93 328533
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Small print
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Changes in systolic BP diastolic BP due to
cocoa intake
Systolic
Diastolic
Dark chocolate 100 g/day ? 5/3 BP reduction
Taubert D. et al. Arch Intern Med 2007 167
626-634
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How
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Pre-
conception
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Breast feeding protects against subsequent
obesityOslo youth study, 635 examined in 1979
1999
Adjusted odds ratio
Months of breast feeding
sex, parents BMI, education, mothers smoking
Kvaavik E et al. J Clin Epidemiol. 2005 58 849
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Tracking of CVD risk factors
Behavioural patterns smoking, physical
activity, eating habits and weight tracking from
childhood, through adolescence to adulthood.
Kvaavik E. Oslo Youth Study Arch Ped Adolesc Med
2004 157 1212
Wilsgaard T. The Tromso Study Am J
Epidemiol 2001 154(5) 418
Twisk JW. The Amsterdam Growth and Health Study
Am J Epidemiol 1997 145 888
Kuh DJ. MRC National survey J Epidemiol
Community Health 1992 46 114
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Obesity prevention in children Four behaviours
to target

• Target behaviours for energy expenditure
• Limit television viewing
• Encourage outdoor play
• Target behaviours for energy intake
• Encourage breastfeeding
• Limit consumption of sugar-sweetened soft drinks

Arch Pediatr Adolesc Med. 2003 157 725
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The DASH diet

• More
• Fruit, vegetables
• Fresh
• Whole grains, beans
• Un-sat oils
• Fish, poultry

• Less
• Sat fat
• Salt
• Processed
• CHOate
• Sugary drinks
• Cholesterol

Goodies - Nuts, green tea, (alcohol ?)

• Circulation 2002 106 3143-421
• Circulation 2004 110 227-239
• Appel LJ et al. OmniHeart Study. JAMA. 2005 294
  2455
• http//www.nhlbi.nih.gov/guidelines/cholesterol/
• http//www.nhlbi.nih.gov/health/public/heart/hbp/d
  ash/

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Fat thin people fail to guess the calorie
content of large meals
Distribution of actual estimated calories of
self-selected (top) experimenter selected
(bottom) fast-food meals by thinner fatter
participants.
Use a smaller plate !
Wansink B et al. Ann Int Med 2006 145 326
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The Danish approach to promoting fruit
vegetables
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P for trend lt0.00161,574 white women
Walking protects against CVD amongst
postmenopausal women, aged 50 79, black and
white, regardless of BMI
Age adjusted RR of CVD
Energy expenditure from walking MET-hr/week
Manson JE, NEJM 2002 347 716-25
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Pedometers promote exercise
Araiza P. Metabolism 2006 55 1382
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• Exercise advice
• 30 mins / day moderate intensity.
• Practical approaches
• Probably starting from scratch.
• Start low, go slow.
• Give the evidence leaflets.
• Describe local facilities parks, sports
  centres.
• Link exercise with daily activities.
• Specific leisure times for elderly.
• GP exercise prescriptions.
• School programs
• Lobby for inclusion of exercise within curriculum.

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Practical approaches
Exercise advice

• Tailor advice to individual.
• Know the area in which your patients live.
• Useful questions
• What did you used to do?
• What do you enjoy?
• Where do you live what local facilities are
  available?
• Where do you work how do you get there?

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Practical approaches
Exercise advice

• Probably starting from scratch.
• Start low, go slow.
• Give the evidence leaflets.
• Describe local facilities parks, sports
  centres.
• Link exercise with daily activities.
• Specific leisure times for elderly.
• GP exercise prescriptions.
• School programs
• Lobby for inclusion of exercise within curriculum.

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Distribution of attributable burden by exposure
levels
Blood pressure Cholesterol
Body mass index
Hypertension
?cholesterol
Obesity
Attributable DALYs (000s)
Exposure levels
Commonly used threshold values for current
definitions
50
The majority of CVD events occur amongst those
with relatively unremarkable blood pressure values
5
25
20
4
3
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Population distribution ()
Stroke mortality / 1000 person years
2
10
1
5
0
0
100 120 140 160 180 200
Systolic BP, mmHg
Population distribution of systolic BP age
adjusted stroke mortality in Whitehall Study, men
40-64, followed for 18 years
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DALYs attributable to high BP by region
endpoint in 2001 
Lawes CMM et al. Lancet 2008 371 1513 Global
burden of blood-pressure-related disease, 2001
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DALYs attributable to high BP 
Men (A) women (B) in low-income middle-income
countries. Men (C) women (D) in high-income
countries.
Lawes CMM et al. Lancet 2008 371 1513 Global
burden of blood-pressure-related disease, 2001
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Global burden of BP-related disease, 2001
Lawes CMM et al. Lancet 2008 371 1513 Global
burden of blood-pressure-related disease, 2001
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The polypill for CVD prevention
1-a-day pill could stop 100,000 heart
deaths Telegraph, Monday 5th May
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Thank you for your attentions.thom_at_imperial.ac.u
k