1. Lifestyle Interventions for the Management of Hypertension
Louise Beesley
Hypertension Nurse Specialist

2. Lifestyle Interventions for the Management of Hypertension
Review current guidelines
Review evidence base for key lifestyle interventions
Explore less common lifestyle interventions

3. So what do the guidelines say?

4. BHS Guidelines for the management of hypertension
BHS IV, 2004 and Update of the NICE Hypertension Guideline, 2006
Guidelines for management of hypertension: report of the fourth Working Party of the British Hypertension Society, 2004 BHS IV
B Williams et al: J Hum Hyp (2004); 18:

5. A population strategy is required to
- prevent the rise in blood pressure with age
- reduce the need for antihypertensive drug therapy
- reduce the CVD burden
Remember primary prevention
BHS IV

6. Lifestyle intervention may -decrease pharmacological intervention
Effective lifestyle modification may decrease BP as much as a single antihypertensive, combinations achieve more
Lifestyle intervention may
-decrease pharmacological intervention
-enhance antihypertensive effect of drugs
-reduce need for multiple drug treatment
-positive influence on overall CVD risk
BHS IV

8. Limitation of alcohol consumption Increased physical activity
Lifestyle measures that lower blood pressure
Weight reduction
Limitation of alcohol consumption
Increased physical activity
Increased fruit and vegetable consumption
Reduced total fat and saturated fat intake
Measures to reduce cardiovascular disease risk
Cessation of smoking
Replacement of saturated fats with mono-unsaturated fats
Increased oily fish intake
BHS IV

9. Encourage use of salt substitutes
Discourage excessive consumption of coffee and other caffeine rich products
Tell patients about local initiatives that provide support and promote lifestyle change
Consider relaxation therapies
Lifestyle advice should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension
Offer guidance and written or audiovisual information
NICE 2006

10. Impact of lifestyle interventions on blood pressure
2-4mmHg
Alcohol
4-9mmHg
Exercise
2-8 mmHg
Salt
8-14 mmHg
Dietary
5-10 mmHg per 10kg weight loss
Weight reduction
Expected systolic blood pressure reduction
Intervention
BHS IV

11. Lifestyle Interventions

12. The effect of weight loss on BP
Estimated 24% of the population in the UK have a BMI > 30
Neter et al (2003):
1mmHg reduction in BP per 1kg weight loss
Weight reduction has beneficial effects on associated risk factors i.e. insulin resistance, diabetes, dyslipidaemia and LVH

13. Clinic measurements Weight Height BMI
Waist measurement – midway between lower rib margin and the ileac crest

14. BMI and Waist measurements
BMI Category
< Underweight
Normal
Overweight
Obese
> Severely Obese
Abdominal obesity
Men >102cm
Women >88cm
Indio Asia decent
Men >90cm
Women >80cm
JBS Guidelines 2005

15. Referral pathway Exercise on prescription Dietician “Weight Watchers”
Obesity clinic
Surgical Intervention

16. Long term benefits of weight reduction
He et al. (2000) “Beneficial effects are still evident 7 years after study ended.”
n= 208 high impact weight reduction advice and support
7 years later 181 brought back
Incidence of hypertension:
19% in weight loss group
40% control group
Effect, despite being an equal amount of weight gain in both groups over the period

17. Dietary interventions and BP
DASH – Dietary approach to stop hypertension diet (2000)‏
Participants with mild hypertension had approx. 11.4mmHg reduction in systolic BP compared to control diet
Combination of a Mediterranean diet with low fat dairy products
Low fat, high fibre including increased amounts of potassium, calcium, and magnesium
Effects potentiated by salt restriction
Diet better tolerated than salt restrictions

18. 5 a day (or 7-9 if possible!)‏
1 portion of fruit or vegetable represents 80g
i.e 1 apple, 1 orange, 1 banana, 2 satsumas, 2 plums, 3 heaped tbsp peas or carrots, 1 bowl of mixed salad
1 glass of 100% fruit juice can replace 1 portion
1 portion of fruit and vegetables a day lowers CVD risk by 4% (Joshipura et al. 2001)‏
Beneficial effects due to array of compound i.e. vitamins and minerals, phytochemicals, antioxidants
Individual compounds not enough – supplements containing isolated compound do not have same effect – may cause more harm than good

19. Physical activity and BP
Aerobic endurance based activities reduce resting BP in adults with normal BP and in those with hypertension
Places demands on the cardiovascular system
Reductions in BP last for up to 22hrs after exercise (ACSM, 2004)‏
BP reductions are independent of weight loss (Whelton et al. 2002)‏

20. Exercise training in the management of and treatment of hypertension
2.4
4.6
6,805
105
Dickenson et al. 2006
3.0
3,936 72
Cornelissen and Fagard 2005
2.5
4.0
2,419 54
Whelton et al. 2002
3.4
2,674 44
Fagard 2001
3.1
4.7
1,553 29
Halbert et al
Decrease
in DBP
(mmHg)‏
in SBP
Number of subjects
RCTs included
Meta-analysis
Adapted from EUROACTION data BJC Sept 2006

21. Exercise Recommendations
Frequency –x5, preferably all days of the week
Intensity – moderate
Time – 30 minutes or more of continuous activity, alternatively 3 bouts of no less than 10 minutes accumulated during the day
Type – aerobic exercise using large muscle groups
Caution if systolic >160mmHg and/or diastolic >110mmHg

22. Alcohol and BP Association seen as long ago as 1917
Study of trench soldiers
“tres grands buveurs” – hypertensive
“sobres” – normotensive
Klatsky (1977) n= 84,000 men
3 or more drinks per day – dose dependent relationship
Beevers (1984) direct pressor effect of alcohol established –observed alcohol consumption and withdrawal

23. Reduction in alcohol consumption may reduce
BP by an average of 3/2 mmHg (Xin 2001)‏
Daily drinking and on empty stomach associated
with higher BP
There should be 2 alcohol free days per week
There are probably no safe alcohol limits
≤ 14 units per week for women and ≤ 21units per week for men
Binge drinking is now defined as >3 units/day
?? Cardioprotective properties……Jackson argued may be due to confounding

24. Assess number of units per week
Number of alcohol free days
Binge drinking
GGT
125ml wine
1 pub shot of spirit (35ml)‏
½ pint lager / beer / cider

25. Wine strength
11.1
10.5
9.6
9.0
8.4
7.5
6.9
750ml
bottle
3.7
3.5
3.2
3.0
2.8
2.5
2.3
250ml
2.6
2.1
1.9
1.8
1.6
175ml
1.7
1.5
1.4
1.3
1.1
125ml
15%
14%
13%
12%
11%
10% 9%
Glass size
The Times Dec 2006

26. Smoking and BP
Cigarette smoking does not appear to be associated with hypertension
BP does rise acutely during smoking leading to underestimation of BP in regular smokers
Extensive observational data show that smoking has a graded adverse effect on risk of cardiovascular complications
Use of nicotine replacement therapies is safe in hypertensives and doubles smoking cessation rates

27. Assess smoking history
- smoker / non smoker
- how long given up
- number of years / pack years
- method of smoking
- previous attempts at cessation
- NRT
- desire to give up
Smoking cessation clinic / NRT

28. Effect on CVD risk Age 51 Gender male SBP 156 Smoker no Hx diabetes no
LVH no
Cholesterol 5.1
HDL 1.2
CVD RISK %
Age 51
Gender male
SBP 156
Smoker yes
Hx diabetes no
LVH no
Cholesterol 5.1
HDL 1.2
CVD RISK %

30. Effect of Salt on Blood pressure
Recommended salt intake is 5g/day
Estimated that average intake is 9.5g/day
A max of 25% comes from adding at table or cooking
Na value x 2.5 to gain NaCl value
DASH Sodium - reduction in blood pressure with lower sodium intake – direct relationship
Few observational studies and virtually no trial data exist on the effect of sodium intake on subsequent cardiovascular disease

31. Sacks et al. N Eng J of Med 2001;344:3-10

33. TOHP I and II, adjusted for age, sex, and clinic
Fig 2 Cumulative incidence of cardiovascular disease (CVD) by sodium intervention
group in
TOHP I and II, adjusted for age, sex, and clinic
Cook, N. R et al. BMJ 2007;334:885
Copyright ©2007 BMJ Publishing Group Ltd.

34. Fig 3 Total mortality by sodium intervention group in TOHP I and II, adjusted for age,
sex, and clinic
Cook, N. R et al. BMJ 2007;334:885
Copyright ©2007 BMJ Publishing Group Ltd.

35. < 5 grams?!!! 1g 0.5g 0.8g 2g 3.5g TOTAL 9.3g Breakfast
30g cornflakes with skimmed milk and red berries
1 Slice brown bread with low fat spread
Lunch
1 tortilla wrap
2 slices “carvery ham”
1 packet popular brand crisps
Apple
Evening meal
Healthy options lasagne, side salad, jacket potato
Yoghurt and strawberries
Snack
2 digestive biscuits, banana 1g
0.5g
0.8g 2g
3.5g
TOTAL 9.3g

36. Salt Friendly??? <0.25g salt per 100g of food - low
Fresh fruit, vegetables
Pulses, lentils
Meat, chicken
Unsalted nuts
Rice
Pasta
Egg noodles
Chicken
Egg
<0.25g salt per 100g of food - low
0.25 – 1.25g salt per 100g of food moderate
>1.25g salt per 100g food heavily salted
High
Canned produce
Processed meats
Ready meals
Packet food
Bread
Some cereals
Cheese
Bottle sauces i.e. ketchup,soy
Bacon/ sausage/ beefburgers
Pates/ smoked or tinned fish

37. Salt substitutes Losalt 131mg of Sodium 346mg of Potassium
1 gram contains:
131mg of Sodium
346mg of Potassium
800mg of Potassium in the average daily diet from salt substitute.
Combined multisource daily intake is approx 3000mg potassium
Guidance on high Potassium intake:
daily range: 1600mg to 5900mg
harmful range: 17,600mg (50g of LoSalt)

38. Effects of other minerals
Potassium: ↓ BP 4.4/2.5 mmHg in hypertensive patients
↓ BP 1.8/1.0 mmHg in normotensives
Observational studies show links to calcium and magnesium
Less consistent evidence supporting omega -3 fatty acids, vits C, E and B6, folate and flavenoids.
NICE/BHS ‘do not give supplements’

39. Caffeine rich products and BP
Potent physiological effects
Caffeine given as tablets resulted in BP elevations ( x4 greater than for caffeinated coffee) Noordzij et al. 2004
Winkelmayer et al. (2005) found association with caffeinated cola drinks and risk of hypertension (but not with caffeinated coffee)‏
Caffeine intake may only be a risk factor in individuals who are genetically slow caffeine metabolisers (Cornelis,2005)

40. Hamer,M (2006) Journal of human hypertension.20, 909-912
Coffee
Effect on health remains equivocal
2 prospective cohort studies give conflicting opinions
- Winkelmayer et al showed no relationship between coffee intake and incidence of hypertension (n=155,594 US women over 12 years)‏
- Klag et al – John Hopkins precursor study
demonstrated a 0.19 and 0.29 mmHg rise in systolic and diastolic respectively (n=1017 men consuming 1 cup of coffee per day
Hamer,M (2006) Journal of human hypertension.20,

41. Hamer,M (2006) Journal of human hypertension. 20, 909-912.
?? Beneficial effects
? Anti-oxidant properties
? Anti-inflammatory effects
? Inhibit harmful effects of other dietary components i.e. inhibition of alcohol- related hypertensive effects by lowering serum GGT
Hamer,M (2006) Journal of human hypertension. 20,

42. Dietary peptides and BP
Certain dietary peptides shown to lower BP
Peptides are now being incorporated into food products
Derived from the milk product casein either through fermentation or enzymatic hydrolysis
IPP (transpeptides isoleucine proline-proline) and VPP (valine proline- proline) inhibit angiotensin converting enzyme
Dose dependent response in reduction of both systolic and diastolic BP

43. Stress management
Often quoted as cause of hypertension – no evidence to support this
Stress and anxiety cause a temporary rise in BP, but when relaxed will fall to normal levels

44. Relaxation Therapies Stress management Meditation Cognitive therapies
Muscle relaxation
Biofeedback
Shown to result in short term reductions in BP, but the interventions studied have been so varied, it is difficult to be prescriptive

45. Changes (start-end) in systolic blood pressure for stress management interventions
Bandolier Oct 2002

46. Resperate “relaxes constricted blood vessels to lower BP”
15mins paced breathing few times per week leads to vasodilation of vascular smooth muscle

47. Herbal remedies
Limited and inadequate evidence available to support the use of garlic, herbal and complimentary medicines to lower BP
- potassium supplement
- dandelion leaf (diuretic)‏
- hawthorn (vasodilator)‏
- linden (vasospasm)‏
- ginkgo biloba (peripheral blood flow)‏
- mistletoe (vasodilator)‏
- ginger (Mg2+,Ca2+,K+)‏

48. Motivation, Motivation, Motivation
NICE 2006
“education alone is unlikely to be effective”
Referral to outside agencies
Support and encouragement
Achievable and sustainable

49. Outcome of annual review of borderline hypertensives