Lifestyle Interventions Are Effective Treatments of Hypertensive Patients

1
Lifestyle Interventions Are Effective Treatments
of Hypertensive Patients
William C. Cushman, MD

• Professor, Preventive Medicine and
  MedicineUniversity of TennesseeCollege of
  Medicine
• Chief, Preventive MedicineVA Medical Center,
  Memphis Memphis, Tennessee

2
JNC 7 Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (lt140/90 mmHg)
(lt130/80 mmHg for those with diabetes or chronic
kidney disease)
Initial Drug Choices
3
Lifestyle Modifications JNC 7
4
(No Transcript)
5
Trial of Nonpharmacologic Interventions in the
Elderly (TONE)Reduction () in Incidence of
Hypertensionor CV Event
Whelton, et al. JAMA 1998279839-46
6
Trials of Hypertension Prevention (TOHP I)Sodium
Excretion and BP Change _at_ 18 Months
Age 30-54 yrs, DBP 80-89 mm Hg
TOHP Hypertension 199322502-12
7
The DASH Dietary Pattern

• Food Group Servings
• Grains 7 to 8
• Vegetables 4 to 5
• Fruits 4 to 5
• Low/non fat dairy 2 to 3
• Meats, poultry, fish 2 or less
• Nuts, seeds, legumes 1

8
BP Effects of DASH Diets
D Systolic
D Diastolic
-1.1
-2.8
-3.0
D BP (mmHg)
-5.5
F/V DASH
BP changes in CONTROL DIET group have been
subtracted
Mean /- 97.5 C.I. sig diff from CONTROL
DIET
9
Systolic BP Effects of DASH Diet by HTN Status
- 3.5
D BP (mmHg)
- 11.4
With hypertension No hypertension
10
A Standard Drink (U.S.)

• Approximately 14 grams of ethanol
• Contained in
• 12 oz glass/can of beer
• 5 oz of table wine
• 1.5 oz of distilled spirits (80 proof)

11
Effects of Alcohol and Caloric Restrictions on BP
in Overweight Men
N86
Baseline BP 137/85 mm Hg
Alcohol ? 3 drinks/d (BL 3.5 drinks/d) Weight ?
7.5 kg (BL 92.5 kg)
Puddey IB, et al. Hypertension 199220533-41
12
Effects of AlcoholReduction Interventions in
Randomized Controlled Trials

• Meta-analysis of 15 randomized controlled trials.
• The median duration of the trials was 8 weeks.
• Subjects reduced their alcohol consumption by a
  median 76 from a baseline intake of 3-6 standard
  drinks/day.
• This resulted in a pooled effect estimate of the
  effects of alcohol reduction on BP of 3.31/2.04
  mm Hg.

Xin X, He J, Whelton PK. Hypertension
2001,381112-7
13
Average Net Change in BP (95CI) with
Alcohol Reduction Interventions in 15 Randomized
Controlled Trials
Xin X, He J, Whelton PK. Hypertension
2001,381112-7
14
Controlled Trial of Exercise in Stage 1 HTN
p0.02
p0.11
10 week n19
Martin, Dubbert, Cushman, et al. Circulation
199081
15
(No Transcript)
16
Weighted Net Change in BP with Endurance Training
(Meta-analysis)
Fagard. J Hypertens 199311(suppl 5)S47-S52
17
Lifestyle Interventions for Prevention or
Treatment of Hypertension

• Intervention
• Exercise
• Weight reduction
• Alcohol intake reduction
• Sodium intake reduction
• DASH diet

• Blood Pressure Effect
• 5-10 mm Hg (gt30 min gt3x/wk)
• 1-2 mm Hg/Kg?
• 1 mm Hg/drink/d?
• 1-3 mm Hg/40 mmol/d?
• 3-10 mm Hg ?

18
Conclusions

• In a newly diagnosed stage 1 hypertensive
  patient, I recommend what I believe to be the
  most important LSM(s) for that patient.
• Then I negotiate whether to also begin AHT drug
  therapy immediately after the HTN is confirmed
  or, if the patient is enthusiastic about
  attempting LSM, follow the patient every 1-2
  months and withhold drugs if the patient is
  making definite progress in LSM and normalizes BP
  within a few months.
• If it is evident the patient is not adhering well
  to LSM or if the BP remains above goal for more
  than a few months, I will recommend initiating
  drug therapy in addition to LSM.

19
I rest my case
20
Effects of Dietary Instruction and Na Excretion
Feedback in Hypertensive Clinic
PatientsReduction in Na Excretion (mmol/24 hr)
N122, 54 Black, BL UNa197 mmol/24hr
Dubbert, Cushman, Meydrech, et al. Behavior
Therapy 199526721-32
21
Effects of Dietary Instruction and Na Excretion
Feedback in Hypertensive Clinic
PatientsReduction in BP (mm Hg) and Weight (kg)
N122, BL BP 142/86 mm Hg, BL Wt 88 kg
Dubbert, Cushman, Meydrech, et al. Behavior
Therapy 199526721-32
22
Trials of Hypertension Prevention (TOHP
I)Systolic and Diastolic Change _at_ 6 Months



N2182, age 30-54 yrs, DBP 80-89 mm Hg
JAMA 19922671213-20
23
Effect of DASH Diet on Systolic Blood Pressure
Sacks, et al. N Engl J Med 20013443-10
Systolic Blood Pressure (mmHg)
Control Diet
DASH Diet
Higher Intermed Lower
Sodium Level
24
Background

• Hemodynamic effects of alcohol have been reported
  at least since the middle of the nineteenth
  century.
• The first population-based study of alcohol use
  and prevalence of HTN was reported in 1915 by a
  French surgeon, Lian
• He found a linear relationship between the amount
  of wine regularly ingested by French troops on
  the Western front and the prevalence of
  hypertension.

25
Epidemiology

• Since Lian there has been a large number of cross
  sectional and prospective population studies
  which have consistently demonstrated a direct and
  positive relationship between ingestion of
  alcoholic beverages and an increase in both the
  level of BP and prevalence of HTN.
• The relationship is most consistent above 2
  drinks/day average intake.

26
Effects of Alcohol and Caloric Restrictions on BP
in Overweight Men
?-----?, normal alcohol intake/normal caloric
intake (n20) ?- - - ?, normal alcohol
intake/low caloric intake (n22) ?-----?, low
alcohol intake/normal caloric intake (n21) ?-
- -?, low alcohol intake/low caloric intake
(n23)
Puddey IB, et al. Hypertension 1992,20533-41
27
(No Transcript)
28
Walking to Work and Risk for HTN in Men the
Osaka Health Survey
N6,017 Japanese men age 35-60 yrs BPlt140/90 _at_ BL

• Variable Multivariate RR 95 CI
• Walk to Work
• 0-10 minutes 1.00 (reference)
• 11-20 minutes 0.91 0.77-1.08
• gt21 minutes 0.70 0.59-0.95
• Walk to work continuous 0.88 0.78-0.98
• variable (per 10 minutes)

Hayashi, et al. Ann Intern Med 199913021-26
29
Exercise Prescription to Develop and Maintain
Cardiorespiratory Fitness(and Control BP)

• Mode of Activity Large muscle activity that is
  rhythmical and aerobic (e.g., walking, running,
  cycling)
• Frequency 3-5 days per week
• Duration 20-60 minutes
• Intensity 60-80 of maximum heart rate (50-85 of
  maximum oxygen uptake

American College of Sports Medicine
30
Trials of Hypertension Prevention (TOHP I)

• Weight reduction intervention produced weight
  loss of 3.9 kg (P lt0.01).
• Sodium reduction interventions lowered urinary
  sodium excretion by 44 mmol/24 h (P lt0.01).
• Despite good compliance, neither stress
  management nor nutritional supplements reduced
  diastolic blood pressure or systolic blood
  pressure significantly (P greater than .05).

JAMA 19922671213-20
31
Trials of Hypertension Prevention, Phase II (TOHP
II)

• Examined weight loss and reduction in sodium
  intake for the prevention of hypertension in 2400
  overweight participants.
• Age 30-54 years, high normal DBP.
• Through 48 months, incidence of hypertension was
  significantly less with each active intervention,
  although effect lessened after 6 months.

Arch Int Med 1997157657
32
Trials of Hypertension Prevention, Phase II (TOHP
II)

• TOHP II showed a 20 reduction in the incidence
  of hypertension with weight loss and reduction in
  sodium intake.
• Incidence based on diastolic blood pressure
  threshold.

Arch Int Med 1997157657
33
Long-term (7-Year) Cumulative Incidence of HTN
after Weight Loss and Sodium Reduction
Interventions in TOHP (Baltimore)
p0.19
p0.02
He, et al. Hypertension 200035544-54
34
Rare Genetic Defects and BP

• Every single gene defect discovered thus far that
  causes chronically elevated or low BP effects
  renal handling of sodium.

Paraphrased from Richard Lifton, American
Society of Hypertension Meeting, 2001
35
The DASH Dietary Pattern

• Food Group Servings
• Grains 7 to 8
• Vegetables 4 to 5
• Fruits 4 to 5
• Low/non fat dairy 2 to 3
• Meats, poultry, fish 2 or less
• Nuts, seeds, legumes 1

36
Lifestyle PackagesCausing gt10 mm Hg BP Fall

• Wt control exercise Kingwell
• Wt salt mod Tone
• Wt alcohol mod Puddey
• Wt fish Bao
• Dash diet Appel
• Protein fibre Burke
• DASH Na?
• PREMIER?
• DEW-IT?