Nonpharmacological prevention and management of hypertension a global

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

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 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 2

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Untreated patients Wing (1998)a Blumenthal (2000)a Fagerberg (1984) Mac. Mahon (1985) Wing (1998)b Fortmann (1988)a Anderssen (1995)a Croft (1986) Blumenthal (2000)b Gordon (1997) Anderssen (1991) Anonymous (1990) Stevens (1993) Anderssen (1995)b Fortmann (1988)b Anonymous (1997) Masuo (2002)a Langford (1991) He (2000) Oberman (1990) Haynes (1984) Stamler (1989) Blumenthal (2000)c Anderssen (1995)c Masuo (2002)b Wing (1998)c Combined Neter et al. Hypertension. 2003; 42: 878 -84 -30 -20 -10 0 Change in systolic blood pressure (mm Hg) 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 10 4

Treated patients Singh (1990) Reisin (1978) Ard (2000) Jalkanen (1991) Lalonde (2002)a Singh (1995) Whelton (1998) Lalonde (2002)b Combined -30 -20 -10 0 10 Change in systolic blood pressure (mm Hg) 5 Neter et al. Hypertension. 2003; 42: 878 -84 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

Trial Of Non-pharmacological intervention in the Elderly (TONE): weight (-3. 5 kg) and sodium (-40 mmol/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. 9 kg and 12/-6 mm. Hg 6 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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 7 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

‘Women sprinkling salt on their husbands to stimulate their sexual performance’ Anonymous woodcut 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 8

DOUBLE-BLIND STUDY OF THREE SODIUM INTAKES AND LONGTERM EFFECTS OF SODIUM RESTRICTION IN ESSENTIAL HYPERTENSION 9 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 Lancet 1989; ii: 1244 -7

Modest salt restriction in older people 10 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 Lancet 1997; 350: 850 -4

Dietary Sodium Reduction and Blood Pressure -5. 0 mm. Hg -2. 0 mm. Hg 17 trials in hypertensives (n=734) 11 trials in normotensives (n=2, 220) >4 wks duration Reduction in sodium ~80 mmol/day 11 J Hum Hypert 2002; 16: 761 -70 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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 Systolic BP (mm. Hg) Diastolic BP (mm. Hg) 95 th 80 th 50 th 20 th 5 th Age (years) 12 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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Normotensive Hypertensive <140 mmol/d 140 -164 mmol/d >=165 mmol/d -12 -10 -8 -6 -4 -2 0 Change in systolic blood pressure (mm Hg) 2 The blood pressure lowering effect of potassium appears to be higher in hypertensives than normotensives and enhanced in patients with a high sodium intake. Potassium supplementation should be considered for the nonpharmacological treatment of hypertension, especially for those unable to reduce their salt intake. Whelton P et al. JAMA 1997; 277: 1624 -32 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 15

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D. A. S. H. diet 132 Control 131 130 129 Fruit & Veg 128 127 126 Combination 125 124 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 8 & 7 6 5 4 3 2 1 lin e 123 Ba se SBP (mm. Hg) • High fruit & vegetables • Low fat dairy products • Whole grains & Nuts • Poultry & Fish • Little red meat, sweets, sugarcontaining drinks • Reduced total and saturated fat weeks N Engl J Med 1997; 336: 1117 -24 17

Systolic blood pressure reduction following the DASH diet and a reduction of salt intake 3. 5 -2. 1 (-3. 4 to – 0. 8) Systolic blood pressure (mm. Hg) 134 3 -4. 6 (-5. 9 to – 3. 2) 132 2. 5 130 2 128 1. 5 126 -1. 3 (-2. 6 to 0. 0) -1. 7 (-3. 0 to – 0. 4) 124 1 122 0. 5 120 0 High Intermediate Level of sodium consumption Control Diet g of sodium consumed per day 136 Low DASH Diet The reduction in salt consumption is a valuable non pharmacological measure to reduce blood pressure; its combination with the DASH diet is additive. Sacks et al. N Eng J Med. 2001; 344: 3 -10. 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 18

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Mean net changes in SBP and DBP Whelton SP et al. Ann Int Med 2002; 136: 493 -503 20 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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Lang et al, 1995 Cushman et al, 1998 Wallace et al, 1988 Maheswaran et al, 1992 Ueshima et al, 1987 Ueshima et al, 1993 Rakic et al, 1981 Rakic et al, 1982 Puddey et al, 1985 Kawano et al, 1998 Parker et al, 1990 Puddey et al, 1992 Cox et al, 1993 Puddey et al, 1986 Howes and Reid, 1986 Systolic blood pressure 76% Combined Lang et al, 1995 Cushman et al, 1998 Maheswaran et al, 1992 Ueshima et al, 1987 Ueshima et al, 1993 Rakic et al, 1981 Rakic et al, 1982 Puddey et al, 1985 Kawano et al, 1998 Parker et al, 1990 Puddey et al, 1992 Cox et al, 1993 Puddey et al, 1986 Howes and Reid, 1986 Diastolic blood pressure 76% Combined -15 -10 0 -5 Reduction in blood pressure (mm Hg) 5 10 Reduction in self-reported daily consumption of alcohol There is a dose-response relation between the reduction in blood pressure following a reduction in alcohol intake. Xin et al. Hypertension. 2001; 38: 1112 -7 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 22

PREMIER Clinical Trial • • • 4 centres RCT 810 adults Women 62% African-Americans 34% BP 120 -159 / 80 -95 mm. Hg • Not on therapy • Treatment arms: – Advice only (n=273) – Established recommend. (n=268) – Established plus DASH (n=269) 3 Baltic-Nordic Meeting on Hypertension rd • Duration: 6 months Vilnius, October 2005 23 JAMA 2003; 289: 2083 -93

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Selected leading causes of death worldwide in 1990 ) g % in 70 lop (~ e es ev tri 3 M d n in ou c 25 Number of deaths (million) 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 Lancet 1997; 349: 1269 -76

Mortality due to leading global risk factors 26 Ezzati M et al. Lancet 2002; 360: 1347 -60 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

Stroke mortality in urban and rural Tanzania Lancet 2001; 355: 1684 -7 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 27

Stages in the epidemiological transition of C. V. D. Low smoking, moderate fat and salt intake Moderate smoking, moderate fat but high salt intake High smoking, fat and salt intake Increasing levels of acculturation, urbanization and affluence 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 28 Cappuccio FP. Int J Epidemiol 2004; 33

“More than a quarter of the world’s 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 2005; 365: 217 -23 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 29

Cappuccio FP; Unpublished 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 30

evalence of detection, management and control of hypertension in Ashanti P=0. 007 P=0. 06 P=0. 05 31 Cappuccio FP et al. Hypertension 2004; 43: 1017 -22 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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Community 6. 4 (0. 5 to 12. 3) dietary salt reduction in Kumasi 4. 5 (-0. 3 to 9. 3) 44 (22 to 66) BASELINE Cappuccio FP et al. Lancet 2000; 356: 677 -8 20 farmers 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 4 WEEKS 33

Reduction in systolic blood pressure achieved by two pilot trials of salt reduction in sub-Saharan Africa Cappuccio FP et al. Lancet 2000; 356: 677 -8 34 Adeyemo AA et al. Ethn Dis 2002; 12: 207 -11 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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Risk of stroke attributable to high blood pressure ~40% ~78% 36 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005

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/m 2) – Reduce salt intake to <100 mmol/day (<6 g Na. Cl or <2. 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 weightlifting) for >30 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 3 rd Baltic-Nordic Meeting on Hypertension Vilnius, October 2005 37