1. OST 524 Diet and Hypertension (www.msu.edu/course/hnf/470) I.NHLBI Joint National Commission VI Treatment Guidelines (www.nhlbi.nih.gov) II.Non-pharmacologic therapies in HTN trt III.Dietary approaches to the trt of HTN IV.DASH trial: results and implications V. Implications of National Dietary Guidance

5. Summary points (Ramsay LE et al. BMJ 1999: 319: 630-635) Use non-pharmacological measures in all hypertensive and borderline hypertensive people Initiate antihypertensive drug treatment in people with sustained systolic blood pressure 160 mm Hg or sustained diastolic blood pressure 100 mm Hg Decide on treatment in people with sustained systolic blood pressure according to the presence or absence of: target organ damage, cardiovascular disease, diabetes, or a 10 year coronary heart disease risk of 15% according to the Joint British Societies coronary heart disease risk assessment programme or risk chart

6. Good evidence from trials shows that several lifestyle modifications lower blood pressure: weight reduction to achieve an ideal body weight via reduced fat and total calorie intake; regular physical exercise designed to improve fitness; this should be predominantly dynamic (brisk walking, for example) rather than isometric (weight training); limiting alcohol consumption to <21 units per week for men and <14 units per week for women;

7. reduced use of salt when preparing food and elimination of excessively salty foods from the diet; increased consumption of fruit and vegetables. Lifestyle modifications that further reduce cardiovascular disease risk are: stopping smoking; reducing total intake of saturated fat, replacing it with PUFA or MUFA fats; increased intake of oily fish; regular physical exercise.

8. Non-pharmacological advice should be offered to all hypertensive people and those with a strong family history of hypertension. Such measures may obviate the need for drug treatment or reduce the dose or number of drugs required to control blood pressure. When drug treatment has to be introduced more quickly, non-pharmacological measures should be instituted in parallel with drug treatment.

9. A philosophical paradigm in which one attempts to explain A philosophical paradigm in which one attempts to explain complex phenomena using relatively simple principles. complex phenomena using relatively simple principles.

10. Dietary Patterns and Mortality Studies Assess effect of specific dietary patterns inAssess effect of specific dietary patterns in longitudinal studies on subsequent mortality. Patterns used include:Patterns used include: Mediterranean:W.H.O.: High vs. Low High MUFA: SFA ratioPUFA/SFA (g) Moderate ethanol consumptionFruit/vegetable High consump. legumes/cereals/Pulses/nuts/seeds Low consump. meat/dairy productsDietary Fiber Protein

11. Results Mediterranean Dietary Pattern and Survival in the Elderly (Trichopoulou et al. (1995) BMJ 311: 1457-60) (Trichopoulou et al. (1995) BMJ 311: 1457-60) In an elderly rural Greek cohort, total diet score was usedIn an elderly rural Greek cohort, total diet score was used as a predictor of hazard of death. No individual dietary component was independentlyNo individual dietary component was independently associated with decreased risk of death. A one unit increase in diet score was associated withA one unit increase in diet score was associated with a significant 17% reduction in overall mortality (95% CI 1-31%).

12. Results W.H.O. Dietary Pattern and Mortality in Elderly Men (Huifbregts et al. (1997) BMJ 315: 13-17) (Huifbregts et al. (1997) BMJ 315: 13-17) In 3 elderly cohorts (Finland, Netherlands, and Italy),In 3 elderly cohorts (Finland, Netherlands, and Italy), healthy diet indicator score was used as a predictor of hazard of death after 20 years of followup.. No individual dietary component was independentlyNo individual dietary component was independently associated with decreased risk of death. Healthy diet indicator score was inversely associatedHealthy diet indicator score was inversely associated with mortality (p for trend <0.05). Relative risk in healthiest vs. least healthy score= 0.87 (95% CI: 0.77-0.98)

13. Assessment of Obesity Weight Gain since age 18 Bjorntorp P. Obesity. Lancet 350: 423-426, 1997 Body Mass Index Waist Circumference Weight (kg) / Height (m) 2 Good Estimate of Central Adiposity Weight (lbs) X 703 Height Squared (in 2 ) Men: 40” Women:35” Underweight < 18 Normal18-24 Overweight25-29 Obese> 30 Level of Fitness Morbid Obesity> 40

14. The Obesity Epidemic U.S.: 20% of men & 25% of women are obese. 97 million Americans are overweight or obese. (59.4% of men and 51% of women) >10% of 4-5 year old children are obese. –~2-fold increase over preceding decade These increases have occurred despite successes in reducing dietary fat as % of kcal. Source: NCHS, National Health and Nutrition Examination Survey,1997

15. Kuczmarski et al. National Health and Nutrition Examination Surveys, MMWR; 43: 818-821,1994.

16. Consequences of Modest Weight Gain 10% increase in weight results in: Fasting Blood Glucose of 2-3 mg/dL Systolic Blood Pressure of 6-7 mm Hg

17. Conditions Associated With Obesity (Relative Risk) Obesity Diabetes Mellitus Gall Bladder Disease Sleep Apnea (Type II) (RR>>3) (RR>>3) (RR>>3) Stroke Hypertension (RR= 2-3) (RR>>3) Coronary Heart Disease Gout Osteoarthritis (RR= 2-3) (RR=2-3) (RR=2-3)

18. Upper Body Fat Distribution Increases Metabolic Complications Central or Visceral Adiposity vs. Subcutaneous Adiposity Excess central or abdominal fat Minimal risk associated is an independent predictor of with lower body obesity. disease risk. Visceral fat is more metabolically active. Highly susceptible to Syndrome X.

19. Insulin Resistance HyperinsulinemiaHDL Cholesterol SYNDROME X VLDL Hypertension Cholesterol Glucose Hypertriglyceridemia Intolerance DEADLY QUARTET Android Obesity Zemel M. 1998. National Conference on Obesity and Co-morbidities, Ft. Myers, FL.

20. Lipoprotein Lipase Leptin IL-6 PAI-1 Adipsin (Complement D) Lactate Serum Free Fatty Acids Angiotensinogen

21. Benefits of Modest Weight Loss Normalizes high blood pressure Blood levels LDL cholesterol Insulin Glycated hemoglobin (HbA1C) Blood glucose Uric acid HDL Cholesterol Improved Quality of Life

22. Since only 47% of Americans have optimal BP, theSince only 47% of Americans have optimal BP, the demographics of aging and its effect of BP are of concern. National guidelines suggest NaCl intakes, reduced alcoholNational guidelines suggest NaCl intakes, reduced alcohol consumption, K consumption (?), and WEIGHT CONTROL. What about non-pharmacologic approaches? Hints--What about non-pharmacologic approaches? Hints-- *Replacing animal products with vegetable products BP *High mineral content (K, Mg), fiber and fat may contribute? *Observational studies indicate inverse associations of BP with: Mg, K, Ca, fiber, and protein in foods Controlling Blood Pressure: Approaches and Hypotheses

23. Trial Participants:459 adults of which 133 had stage I HTN (B.P. 140-159/90-99) (B.P. 140-159/90-99) 49% women; 60% African-American Acclimation Diet:Low fruits (F), vegetables (V), dairy products ~40% fat for 3 weeks The Diets:1.Control Diet: average for fat, F&V consumption 2.8-10 servings of F&V, ~35+% fat 3.Low-fat (<30% kcal), 8-10 servings of F&V, Rich in low-fat dairy foods. Duration:8 weeks New Engl J Med (1997) 336: 1117-1124

24. NutrientControl V & F Combo K (mg)1700 4700 4700 Mg (mg) 185 500 500 Ca (mg) 450 450 1240 Fiber (g) 9 31 31 Na (g)3-3.5 3-3.5 3-3.5 Total Fat 36 36 26 (% of kcal)

25. Source: http://dash.bwh.harvard.edu/

27. DASH Comments DASH Comments B.P. reductions occurred quickly (2 weeks) and were maintained throughout the study. Investigators estimated that incidence of CHD and strokes in U.S. could be reduced by 15% and 27%, respectively, if DASH diet were followed.

29. Dietary Guidelines 2000 (Proposed) Dietary Guidelines 2000 (Proposed) Aim, Build, Choose--for Good Health Build a Healthy Base Choose Sensibly Aim for Fitness

30. Dietary Guidelines 2000 (proposed) Aim 1.Aim for a healthy weight. 2.Be physically active each day. Build3.Let the Pyramid guide your choices. 4.Choose a variety of grains daily, especially whole grains. 5.Choose a variety of fruits and vegetables daily. 6.Keep food safe to eat.

31. Choose Sensibly Choose Sensibly 7.Choose a diet that is low in saturated fat and cholesterol and moderate in total fat. 8.Choose beverages and foods that limit your intake of sugars. 9.Choose and prepare foods with less salt. 10.If you drink alcoholic beverages, do 10.If you drink alcoholic beverages, do so in moderation.