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

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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

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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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Neter et al. Hypertension.200342878-84
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Neter et al. Hypertension.200342878-84
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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
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DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND
LONG-TERM EFFECTS OF SODIUM RESTRICTION IN
ESSENTIAL HYPERTENSION
Lancet 1989 ii1244-7
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Modest salt restriction in older people
Lancet 1997350850-4
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Dietary Sodium Reduction and Blood Pressure
17 trials in hypertensives (n734) 11 trials in
normotensives (n2,220) gt4 wks duration Reduction
in sodium 80 mmol/day
J Hum Hypert 200216761-70
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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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Whelton P et al. JAMA 19972771624-32
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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 19973361117-24
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-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. 20013443-10.
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Mean net changes in SBP and DBP
Whelton SP et al. Ann Int Med 2002136493-503
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There is a dose-response relation between the
reduction in blood pressure following a reduction
in alcohol intake.
Xin et al. Hypertension.2001381112-7
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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 (n273)
• Established recommend. (n268)
• Established plus DASH (n269)
• Duration 6 months

JAMA 2003 289 2083-93
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Selected leading causes of death worldwide in 1990
3M (70) in developing countries
Number of deaths (million)
Lancet 19973491269-76
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Mortality due to leading global risk factors
Ezzati M et al. Lancet 20023601347-60
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Stroke mortality in urban and rural Tanzania
Lancet 20013551684-7
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Stages in the epidemiological transition of C.V.D.
Cappuccio FP. Int J Epidemiol 2004 33387-8
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More than a quarter of the worlds 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 2005365217-23
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Cappuccio FP Unpublished
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Prevalence of detection, management and control
of hypertension in Ashanti
P0.007
P0.06
P0.05
Cappuccio FP et al. Hypertension 2004 43
1017-22
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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 2000356677-8
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Reduction in systolic blood pressure achieved by
two pilot trials of salt reduction in
sub-Saharan Africa
Cappuccio FP et al. Lancet 2000356677-8
Adeyemo AA et al. Ethn Dis 200212 207-11
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Risk of stroke attributable to high blood
pressure
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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 lt100 mmol/day (lt6g NaCl or
  lt2.4g Na/day)
• Limit alcohol consumption to lt3 units/day for men
  and lt2 units/day for women
• Engage in regular aerobic physical exercise
  (brisk walking rather than weightlifting) for gt30
  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